Provider Demographics
NPI:1609170513
Name:JENKINS, LUKE FORREST (MHS, PA-C)
Entity type:Individual
Prefix:
First Name:LUKE
Middle Name:FORREST
Last Name:JENKINS
Suffix:
Gender:M
Credentials:MHS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 N MARIO CAPECCHI DR. 2 SOUTH
Mailing Address - Street 2:RADIOLOGY AND IMAGING SCIENCES
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84112
Mailing Address - Country:US
Mailing Address - Phone:801-581-2967
Mailing Address - Fax:
Practice Address - Street 1:50 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-4162
Practice Address - Country:US
Practice Address - Phone:801-581-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-06
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 21290363AM0700X
UT7777059-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
00PA212900OtherBLUE SHIELD
CAEN986YMedicare PIN
CAEN986ZMedicare PIN