Provider Demographics
NPI:1427057132
Name:JENKINSON, ERIC J (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:J
Last Name:JENKINSON
Suffix:
Gender:M
Credentials:MD
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 991950
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96099-1950
Mailing Address - Country:US
Mailing Address - Phone:530-246-2457
Mailing Address - Fax:530-246-5632
Practice Address - Street 1:1255 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-0814
Practice Address - Country:US
Practice Address - Phone:530-246-2467
Practice Address - Fax:530-246-5632
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01050809A2080S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200216530Medicaid
IN250011958OtherRAIL ROAD MEDICARE
IN250011958OtherRAIL ROAD MEDICARE
IN200216530Medicaid
IN250011958Medicare PIN
IN058940SSMedicare ID - Type Unspecified