Provider Demographics
NPI:1063137123
Name:JENKINS, KYLE MICHAEL (PA-C)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:MICHAEL
Last Name:JENKINS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1617 MAPLE VIEW CT
Mailing Address - Street 2:
Mailing Address - City:STREETSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:44241-6345
Mailing Address - Country:US
Mailing Address - Phone:330-204-8021
Mailing Address - Fax:
Practice Address - Street 1:18901 LAKE SHORE BLVD
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44119-1078
Practice Address - Country:US
Practice Address - Phone:216-531-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-11
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant