1285669150 NPI number — LARRY CARLTON JENKINS

Table of content: LARRY CARLTON JENKINS (NPI 1285669150)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285669150 NPI number — LARRY CARLTON JENKINS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JENKINS
Provider First Name:
LARRY
Provider Middle Name:
CARLTON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285669150
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
912 HIGHWAY 15
Provider Second Line Business Mailing Address:
PO BOX 128
Provider Business Mailing Address City Name:
STRINGER
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39481-0128
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-649-4418
Provider Business Mailing Address Fax Number:
601-649-4487

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
912 HIGHWAY 15
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STRINGER
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39481-4230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-649-4418
Provider Business Practice Location Address Fax Number:
601-649-4487
Provider Enumeration Date:
07/11/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  05068/11.1 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336S0011X , with the licence number: 05321/02.5 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00440829 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00330648 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1700073905 . This is a "MEDICARE NPI" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".