Provider Demographics
NPI:1285704726
Name:JENKINS, COURTNEY RENAE (CRNA)
Entity type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:RENAE
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 1:130 MOOREFIELD PLACE
Mailing Address - Street 2:
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560
Mailing Address - Country:US
Mailing Address - Phone:304-760-2182
Mailing Address - Fax:
Practice Address - Street 1:501 MORRIS ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301
Practice Address - Country:US
Practice Address - Phone:304-388-6261
Practice Address - Fax:304-388-3604
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV57549163W00000X
WV53978367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
430078761OtherRR MEDICARE
WV2602847000Medicaid
WVJE7308491Medicare ID - Type Unspecified