Healthcare Provider Details

I. General information

NPI: 1174687123
Provider Name (Legal Business Name): BARRY J JENKINS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 11/16/2021
Certification Date: 11/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1348 WALTON WAY STE 6500
AUGUSTA GA
30901-5111
US

IV. Provider business mailing address

1348 WALTON WAY STE 6500
AUGUSTA GA
30901-5111
US

V. Phone/Fax

Practice location:
  • Phone: 706-722-2118
  • Fax: 706-722-0342
Mailing address:
  • Phone: 706-722-2118
  • Fax: 706-722-0342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number53249
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number53249
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: