Provider Demographics
NPI:1154434686
Name:JENKINS, SUSAN D (CRNA)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:D
Last Name:JENKINS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:COFFEYVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:67337-3306
Mailing Address - Country:US
Mailing Address - Phone:620-251-1200
Mailing Address - Fax:
Practice Address - Street 1:1400 W 4TH ST
Practice Address - Street 2:
Practice Address - City:COFFEYVILLE
Practice Address - State:KS
Practice Address - Zip Code:67337-3306
Practice Address - Country:US
Practice Address - Phone:620-251-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1354266031163W00000X
MO108151163W00000X
MO2010035242367500000X
KS4355524367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSP00380549OtherRR MEDICARE
KS200400270AMedicaid
MO1154434686Medicare UPIN
KS143E770Medicare PIN