Provider Demographics
NPI:1194987198
Name:JENKINS, KATIE
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:JENKINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S WIND RIVER DR
Mailing Address - Street 2:D202
Mailing Address - City:DOUGLAS
Mailing Address - State:WY
Mailing Address - Zip Code:82633-2332
Mailing Address - Country:US
Mailing Address - Phone:307-202-2758
Mailing Address - Fax:
Practice Address - Street 1:100 S WIND RIVER DR
Practice Address - Street 2:D202
Practice Address - City:DOUGLAS
Practice Address - State:WY
Practice Address - Zip Code:82633-2332
Practice Address - Country:US
Practice Address - Phone:307-202-2758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY125990300OtherMEDICARE PROVIDER NUMBER