Healthcare Provider Details

I. General information

NPI: 1679792071
Provider Name (Legal Business Name): JANE E KENNEDY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2455 BENNETT VALLEY RD STE B205
SANTA ROSA CA
95404-5667
US

IV. Provider business mailing address

2455 BENNETT VALLEY RD STE B205
SANTA ROSA CA
95404-5667
US

V. Phone/Fax

Practice location:
  • Phone: 707-536-9722
  • Fax: 707-843-5475
Mailing address:
  • Phone: 707-536-9722
  • Fax: 707-843-5475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number13881
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: