1225069123 NPI number — FREDERICK D JENKIN PHYSICIAN

Table of content: FREDERICK D JENKIN PHYSICIAN (NPI 1225069123)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225069123 NPI number — FREDERICK D JENKIN PHYSICIAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JENKIN
Provider First Name:
FREDERICK
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHYSICIAN
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JENKIN
Provider Other First Name:
FREDERICK
Provider Other Middle Name:
D
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHYSICIAN
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1225069123
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 511405
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90051-7960
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-284-2771
Provider Business Mailing Address Fax Number:
800-334-1041

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7050 PARKWAY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA MESA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91942-1535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-774-5157
Provider Business Practice Location Address Fax Number:
858-731-1021
Provider Enumeration Date:
07/06/2006

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: 207Q00000X , with the licence number:  20A5034 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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