Healthcare Provider Details

I. General information

NPI: 1487266714
Provider Name (Legal Business Name): CHARLENE JENKINS NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2020
Last Update Date: 11/25/2020
Certification Date: 11/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S PARK ST
MADISON WI
53715-1830
US

IV. Provider business mailing address

PO BOX 678268
DALLAS TX
75267-8268
US

V. Phone/Fax

Practice location:
  • Phone: 608-251-6100
  • Fax:
Mailing address:
  • Phone: 414-732-5405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8919-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: