Provider Demographics
NPI:1588130702
Name:JENKINS, ELISABETH S (PA-C)
Entity type:Individual
Prefix:
First Name:ELISABETH
Middle Name:S
Last Name:JENKINS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELESABETH
Other - Middle Name:S
Other - Last Name:DESROCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:320 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CROSBY
Mailing Address - State:MN
Mailing Address - Zip Code:56441-1645
Mailing Address - Country:US
Mailing Address - Phone:218-546-7000
Mailing Address - Fax:218-546-4400
Practice Address - Street 1:320 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CROSBY
Practice Address - State:MN
Practice Address - Zip Code:56441-1645
Practice Address - Country:US
Practice Address - Phone:218-546-7000
Practice Address - Fax:218-546-4400
Is Sole Proprietor?:No
Enumeration Date:2018-10-15
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12818363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant