Healthcare Provider Details

I. General information

NPI: 1609170513
Provider Name (Legal Business Name): LUKE FORREST JENKINS MHS, PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2011
Last Update Date: 07/12/2024
Certification Date: 11/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N MEDICAL DR
SALT LAKE CITY UT
84132-4162
US

IV. Provider business mailing address

30 N MARIO CAPECCHI DR. 2 SOUTH RADIOLOGY AND IMAGING SCIENCES
SALT LAKE CITY UT
84112
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-2121
  • Fax:
Mailing address:
  • Phone: 801-581-2967
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7777059-1206
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA 21290
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: