Provider Demographics
NPI:1457234429
Name:JENKINS, BRANDON
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:JENKINS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3017 S OHIO AVE
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-5956
Mailing Address - Country:US
Mailing Address - Phone:208-514-8384
Mailing Address - Fax:
Practice Address - Street 1:2814 S INDIANA AVE
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-5925
Practice Address - Country:US
Practice Address - Phone:208-514-8384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-28
Last Update Date:2025-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty