Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223G0001X | General Practice | 12012319A | IN |
Y | 213EG0000X | General Practice | 12012319A | IN |
N | 1223G0001X | General Practice | DN 21241 | FL |
N | 213EG0000X | General Practice | DN 21241 | FL |
NPI | 1003296823 |
---|---|
Provider Name | Jordan Michael Jenkins |
First Address | Noblesville, IN 46062-9048 |
Second Address | Kokomo, IN 46902-6027 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/06/2015 |
Last Update Date | 02/04/2021 |