Provider Demographics
NPI:1952749103
Name:JENKINS, KEYONNA MICOLE (MD)
Entity Type:Individual
Prefix:DR
First Name:KEYONNA
Middle Name:MICOLE
Last Name:JENKINS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DWIGHT D EISENHOWER ARMY MEDICAL CENTER
Mailing Address - Street 2:300 W HOSPITAL RD
Mailing Address - City:FORT GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905-5741
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 E HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:FORT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30813-5741
Practice Address - Country:US
Practice Address - Phone:067-873-2867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-10
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME121166208100000X
TXR8385208VP0014X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX396151801Medicaid