Healthcare Provider Details

I. General information

NPI: 1689012916
Provider Name (Legal Business Name): LYDIA JENKINS D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2013
Last Update Date: 09/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7720 E CALLE DEL MINIQUE
TUCSON AZ
85750-7055
US

IV. Provider business mailing address

809 IRONGATE CT
NEWPORT NEWS VA
23602-9626
US

V. Phone/Fax

Practice location:
  • Phone: 520-235-6267
  • Fax:
Mailing address:
  • Phone: 520-235-6267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR2241
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: