Healthcare Provider Details

I. General information

NPI: 1023083680
Provider Name (Legal Business Name): SHANNON JENKINS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 12/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2860 CHANNING WAY SUITE 100
IDAHO FALLS ID
83404-7531
US

IV. Provider business mailing address

2860 CHANNING WAY SUITE 100
IDAHO FALLS ID
83404-7531
US

V. Phone/Fax

Practice location:
  • Phone: 208-535-4575
  • Fax: 208-535-4569
Mailing address:
  • Phone: 208-535-4575
  • Fax: 208-535-4569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number3863
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberO0424
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: