Healthcare Provider Details

I. General information

NPI: 1841230711
Provider Name (Legal Business Name): JAY CARL JENKINS OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 06/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6525A W HOUGHTON LAKE DR
HOUGHTON LAKE MI
48629-9789
US

IV. Provider business mailing address

6525A W HOUGHTON LAKE DR
HOUGHTON LAKE MI
48629-9789
US

V. Phone/Fax

Practice location:
  • Phone: 989-422-5731
  • Fax: 989-422-2534
Mailing address:
  • Phone: 989-422-5731
  • Fax: 989-422-2534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901003630
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: