Provider Demographics
NPI:1881612489
Name:JENKINS, EDSON HENRY (DC)
Entity type:Individual
Prefix:MR
First Name:EDSON
Middle Name:HENRY
Last Name:JENKINS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 SOUTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTAINE
Mailing Address - State:OH
Mailing Address - Zip Code:43311-1724
Mailing Address - Country:US
Mailing Address - Phone:937-592-5525
Mailing Address - Fax:937-592-5522
Practice Address - Street 1:500 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:BELLEFONTAINE
Practice Address - State:OH
Practice Address - Zip Code:43311-1724
Practice Address - Country:US
Practice Address - Phone:937-592-5525
Practice Address - Fax:937-592-5522
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH736111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0423152Medicaid
T47107Medicare UPIN
JE0473143Medicare ID - Type Unspecified