Healthcare Provider Details

I. General information

NPI: 1831184688
Provider Name (Legal Business Name): JERRY JENKINS II DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 08/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

533 GANDY ST NE
RUSSELLVILLE AL
35653-1965
US

IV. Provider business mailing address

PO BOX 1412
RUSSELLVILLE AL
35653-3212
US

V. Phone/Fax

Practice location:
  • Phone: 256-331-3338
  • Fax: 256-331-2890
Mailing address:
  • Phone: 256-331-3338
  • Fax: 256-331-2890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberM221
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: