Provider Demographics
NPI:1306901186
Name:JENKS, KEN (PA)
Entity type:Individual
Prefix:
First Name:KEN
Middle Name:
Last Name:JENKS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 340
Mailing Address - Street 2:
Mailing Address - City:NATURITA
Mailing Address - State:CO
Mailing Address - Zip Code:81422-0340
Mailing Address - Country:US
Mailing Address - Phone:970-865-2665
Mailing Address - Fax:970-865-2674
Practice Address - Street 1:421 W ADAMS
Practice Address - Street 2:
Practice Address - City:NATURITA
Practice Address - State:CO
Practice Address - Zip Code:81422
Practice Address - Country:US
Practice Address - Phone:970-865-2665
Practice Address - Fax:970-865-2674
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA 1103363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
840820573004OtherROCKY MTN HMO
CO2712462Medicaid
020250699OtherWORKERS COMP
COJEJ63808OtherANTHEM BLUE CROSS
020250699OtherWORKERS COMP
R32096Medicare UPIN