Healthcare Provider Details

I. General information

NPI: 1619210515
Provider Name (Legal Business Name): GABRIEL JENKO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2013
Last Update Date: 03/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3551 ROGER BROOKE DR MCHE/ME
SAN ANTONIO TX
78234-4504
US

IV. Provider business mailing address

1701 E CAPITOL AVE APT 1
BISMARCK ND
58501-2187
US

V. Phone/Fax

Practice location:
  • Phone: 210-916-5545
  • Fax:
Mailing address:
  • Phone: 701-741-6536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: