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NPI Code Detail

MEDICARE: DR. THEODORA E JENKINS DO

MEDICARE: DR. THEODORA E JENKINS DO
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine Physician02001255AIN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
102001255AOTHERININ LICENSE
202001255BOTHERINCSR

General Provider Information

NPI Number : 1720199524
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. THEODORA E JENKINS DO
Provider Business Mailing Address
First Line : PO BOX 4780
Second Line :
City : BLOOMINGTON
State : IN
Zip : 47402-4780
Country : US
Telephone Number : 812-336-1690
Fax Number : 812-349-1311
Provider Business Practice Location Address
First Line : 650 N GIRLS SCHOOL RD
Second Line :
City : INDIANAPOLIS
State : IN
Zip : 46214-3672
Country : US
Telephone Number : 317-271-5080
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/31/2006
Last Update Date : 03/07/2023

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