Healthcare Provider Details

I. General information

NPI: 1255351797
Provider Name (Legal Business Name): JAN MALLOY KENNAUGH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 E 19TH AVE SUITE 5300
DENVER CO
80218-1216
US

IV. Provider business mailing address

1601 E 19TH AVE SUITE 5300
DENVER CO
80218-1216
US

V. Phone/Fax

Practice location:
  • Phone: 303-839-7440
  • Fax: 303-839-7210
Mailing address:
  • Phone: 303-839-7440
  • Fax: 303-839-7210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number25650
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: