Provider Demographics
NPI:1861586190
Name:JENKINS, MARY (PA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:JENKINS
Suffix:
Gender:F
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 190
Mailing Address - Street 2:
Mailing Address - City:TOPPENISH
Mailing Address - State:WA
Mailing Address - Zip Code:98948-0190
Mailing Address - Country:US
Mailing Address - Phone:509-865-6175
Mailing Address - Fax:
Practice Address - Street 1:602 E NOB HILL BLVD
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98901-3534
Practice Address - Country:US
Practice Address - Phone:509-248-3334
Practice Address - Fax:509-453-6144
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10000693363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8100935OtherCHPW
WA8100935Medicaid
23807OtherGROUP HEALTH
WAJE6901OtherREGENCE
WA68101OtherL & I
GAB22220Medicare ID - Type Unspecified
WAJE6901OtherREGENCE