Healthcare Provider Details

I. General information

NPI: 1659978534
Provider Name (Legal Business Name): JESSICA MARIE KENNEDY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2020
Last Update Date: 10/05/2020
Certification Date: 10/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6401 FAY RANCH RD
WELDON CA
93283-9735
US

IV. Provider business mailing address

5225 KELSO VALLEY RD
WELDON CA
93283-9564
US

V. Phone/Fax

Practice location:
  • Phone: 760-378-4000
  • Fax:
Mailing address:
  • Phone: 760-378-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95026236
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: