1639242423 NPI number — LORRAINE K. JENKINS CAC

Table of content: LORRAINE K. JENKINS CAC (NPI 1639242423)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639242423 NPI number — LORRAINE K. JENKINS CAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JENKINS
Provider First Name:
LORRAINE
Provider Middle Name:
K.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CAC
Provider Gender Code:
F

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:
1639242423
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
35572 POPLAR NECK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLARDS
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21874-1340
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-835-2977
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
WACS
Provider Second Line Business Practice Location Address:
11827 OCEAN GATEWAY
Provider Business Practice Location Address City Name:
OCEAN CITY
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21842
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-213-0202
Provider Business Practice Location Address Fax Number:
410-213-1408
Provider Enumeration Date:
11/17/2006

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: 101YA0400X , with the licence number:  ACO164 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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