1316234727 NPI number — SANDRA B JENKINSON CGC

Table of content: SANDRA B JENKINSON CGC (NPI 1316234727)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316234727 NPI number — SANDRA B JENKINSON CGC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JENKINSON
Provider First Name:
SANDRA
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CGC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STONE
Provider Other First Name:
SANDRA
Provider Other Middle Name:
B
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CGC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1316234727
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/04/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6626 E 75TH ST
Provider Second Line Business Mailing Address:
STE 500
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46250-2805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1440 E COUNTY LINE RD STE 3200
Provider Second Line Business Practice Location Address:
SUITE 3200
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46227-0963
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-621-9254
Provider Business Practice Location Address Fax Number:
317-957-2712
Provider Enumeration Date:
07/06/2011

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: 170300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 300008011 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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