1609170513 NPI number — LUKE FORREST JENKINS MHS, PA-C

Table of content: LUKE FORREST JENKINS MHS, PA-C (NPI 1609170513)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609170513 NPI number — LUKE FORREST JENKINS MHS, PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JENKINS
Provider First Name:
LUKE
Provider Middle Name:
FORREST
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MHS, PA-C
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:
1609170513
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30 N MARIO CAPECCHI DR. 2 SOUTH
Provider Second Line Business Mailing Address:
RADIOLOGY AND IMAGING SCIENCES
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-581-2967
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
50 N MEDICAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84132-4162
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-581-2121
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/06/2011

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: 363AM0700X , with the licence number:  PA 21290 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 7777059-1206 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00PA212900 . This is a "BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




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