Provider Demographics
NPI:1801079017
Name:STACY JENKINS, MD, PLC
Entity type:Organization
Organization Name:STACY JENKINS, MD, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STACY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-618-9400
Mailing Address - Street 1:44555 WOODWARD AVE.
Mailing Address - Street 2:SUITE 202
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341
Mailing Address - Country:US
Mailing Address - Phone:248-499-9390
Mailing Address - Fax:248-499-9385
Practice Address - Street 1:44555 WOODWARD AVE.
Practice Address - Street 2:SUITE 202
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341
Practice Address - Country:US
Practice Address - Phone:248-499-9390
Practice Address - Fax:248-499-9385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207V00000X
207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4493396Medicaid
MIBJ4930029OtherDEA#