Healthcare Provider Details

I. General information

NPI: 1558904961
Provider Name (Legal Business Name): BRETT JENKINS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2019
Last Update Date: 07/18/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2815 LAKELAND HILLS BLVD
LAKELAND FL
33805-2224
US

IV. Provider business mailing address

1324 LAKELAND HILLS BLVD ATTN: MANAGED CARE DEPT
LAKLELAND FL
33805
US

V. Phone/Fax

Practice location:
  • Phone: 863-284-5000
  • Fax:
Mailing address:
  • Phone: 863-687-1100
  • Fax: 863-630-6528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP11003460
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: