Healthcare Provider Details

I. General information

NPI: 1043293103
Provider Name (Legal Business Name): SALLY JEAN KENNEDY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1898 E SOUTHERN AVE
TEMPE AZ
85282-5836
US

IV. Provider business mailing address

2322 S. ROGERS #54
MESA AZ
85202-6561
US

V. Phone/Fax

Practice location:
  • Phone: 480-838-0068
  • Fax: 480-838-3409
Mailing address:
  • Phone: 480-820-7957
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN-39547
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN-39547
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: