Provider Demographics
NPI:1053515338
Name:JENKINS, LONI ELISE (MD)
Entity type:Individual
Prefix:
First Name:LONI
Middle Name:ELISE
Last Name:JENKINS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1065 JODECO RD
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-4953
Mailing Address - Country:US
Mailing Address - Phone:678-284-6300
Mailing Address - Fax:678-284-6282
Practice Address - Street 1:3579 HIGHWAY 138 SE
Practice Address - Street 2:SUITE 101
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-4142
Practice Address - Country:US
Practice Address - Phone:770-507-0029
Practice Address - Fax:770-507-9990
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC141367207Q00000X
GA063358207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC141367OtherRESIDENT TRAINING LICENSE
GA806901621AMedicaid
GA806901621AMedicaid