Basic Information
| Provider Information | |||||||||
| NPI: | 1518958404 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENKINS | ||||||||
| FirstName: | KATHY | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 LONGWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021155724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6173557275 | ||||||||
| FaxNumber: | 6038938886 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 LONGWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021155724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6173552793 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2005 | ||||||||
| LastUpdateDate: | 11/18/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 72081 | MA | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0202X | 72081 | MA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 3114520 | 05 | MA | MEDICAID | 604501 | 01 | MA | HARVARD PILGRIM | OTHER | KJ03671 | 05 | RI | MEDICAID | 1508016 | 05 | NY | MEDICAID | 7613741 | 01 | NC | MEDICAID NC | OTHER | B20216801 | 01 | MA | CIGNA MA | OTHER | 99085901 | 01 | MA | NETWORK HEALTH | OTHER | 300006034 | 05 | NH | MEDICAID | 7500149 | 01 | MA | UNITED HEALTHCARE MA | OTHER | J14168 | 01 | MA | BCBS MA | OTHER |