1598036071 NPI number — KRISTA E JENKINS PA

Table of content: KRISTA E JENKINS PA (NPI 1598036071)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598036071 NPI number — KRISTA E JENKINS PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JENKINS
Provider First Name:
KRISTA
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WELLENKAMP
Provider Other First Name:
KRISTA
Provider Other Middle Name:
E
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1598036071
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
660 MASON RIDGE CENTER DR STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63141-8512
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-448-3791
Provider Business Mailing Address Fax Number:
314-996-7658

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20 PROGRESS POINT PKWY STE 108
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
O FALLON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63368-2207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-577-1493
Provider Business Practice Location Address Fax Number:
618-498-7518
Provider Enumeration Date:
01/16/2012

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: 363A00000X , with the licence number:  085004248 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 085004248 . This is a "LICENSE NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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