Healthcare Provider Details

I. General information

NPI: 1427057132
Provider Name (Legal Business Name): ERIC J JENKINSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 08/03/2020
Certification Date: 08/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1255 LIBERTY ST
REDDING CA
96001-0814
US

IV. Provider business mailing address

PO BOX 991950
REDDING CA
96099-1950
US

V. Phone/Fax

Practice location:
  • Phone: 530-246-2467
  • Fax: 530-246-5632
Mailing address:
  • Phone: 530-246-2457
  • Fax: 530-246-5632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number01050809A
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier200216530
Identifier TypeMEDICAID
Identifier StateIN
Identifier Issuer
# 2
Identifier250011958
Identifier TypeOTHER
Identifier StateIN
Identifier IssuerRAIL ROAD MEDICARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: