Healthcare Provider Details

I. General information

NPI: 1215018502
Provider Name (Legal Business Name): GREGORY DEAN JENKINS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 08/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24355 LYONS AVE #130
NEWHALL CA
91321-2300
US

IV. Provider business mailing address

PO BOX 221976
NEWHALL CA
91322-1976
US

V. Phone/Fax

Practice location:
  • Phone: 661-255-9440
  • Fax: 661-255-7591
Mailing address:
  • Phone: 661-255-9355
  • Fax: 661-255-7591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA40935
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA40935
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: