Provider Demographics
NPI:1841315041
Name:JENKINS, CHARLES MICHAEL (DPH)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:MICHAEL
Last Name:JENKINS
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 OLD BLACKSFERRY LN
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:TN
Mailing Address - Zip Code:37716-7040
Mailing Address - Country:US
Mailing Address - Phone:865-945-3743
Mailing Address - Fax:
Practice Address - Street 1:643 EDGEMOOR RD
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:TN
Practice Address - Zip Code:37849-7146
Practice Address - Country:US
Practice Address - Phone:865-945-3333
Practice Address - Fax:865-945-3449
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5835183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist