Provider Demographics
NPI:1215929757
Name:JENKINS, EVERETTE EARL JR (MD)
Entity type:Individual
Prefix:
First Name:EVERETTE
Middle Name:EARL
Last Name:JENKINS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:E.
Other - Middle Name:EARL
Other - Last Name:JENKINS
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 6426
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24068-6426
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:222 S HERLONG AVE
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1158
Practice Address - Country:US
Practice Address - Phone:803-329-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8250174400000X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
25942OtherMEDCOST
SC082500Medicaid
D90759Medicare UPIN
25942OtherMEDCOST