Provider Demographics
NPI:1548650401
Name:JENKINS, KRYSTAL (DO)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:JENKINS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:775 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-6336
Mailing Address - Country:US
Mailing Address - Phone:718-949-0146
Mailing Address - Fax:
Practice Address - Street 1:24108 140TH AVE
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:NY
Practice Address - Zip Code:11422-2022
Practice Address - Country:US
Practice Address - Phone:718-949-0146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-30
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY288456207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty