Healthcare Provider Details

I. General information

NPI: 1760249247
Provider Name (Legal Business Name): KIMBERLY JENKINS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2024
Last Update Date: 02/02/2025
Certification Date: 02/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16515 S 40TH ST
PHOENIX AZ
85048-0558
US

IV. Provider business mailing address

16515 S 40TH ST
PHOENIX AZ
85048-0558
US

V. Phone/Fax

Practice location:
  • Phone: 480-712-8319
  • Fax:
Mailing address:
  • Phone: 480-712-8319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF02241000
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: