Provider Demographics
NPI:1194155598
Name:JENKS, MARY KAYE (APRN-NP-C)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:KAYE
Last Name:JENKS
Suffix:
Gender:F
Credentials:APRN-NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20806 DITTO CREEK RD
Mailing Address - Street 2:
Mailing Address - City:OASIS
Mailing Address - State:ID
Mailing Address - Zip Code:83647-5034
Mailing Address - Country:US
Mailing Address - Phone:208-796-2119
Mailing Address - Fax:
Practice Address - Street 1:20806 DITTO CREEK RD
Practice Address - Street 2:
Practice Address - City:OASIS
Practice Address - State:ID
Practice Address - Zip Code:83647-5034
Practice Address - Country:US
Practice Address - Phone:208-796-2119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-21
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP1347A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily