Healthcare Provider Details

I. General information

NPI: 1649455718
Provider Name (Legal Business Name): JENNIFER WING KENNEDY CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2008
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1875 CENTURY BLVD NE STE 150
ATLANTA GA
30345-3323
US

IV. Provider business mailing address

403 S CANDLER ST
DECATUR GA
30030-3748
US

V. Phone/Fax

Practice location:
  • Phone: 404-633-4595
  • Fax: 404-633-6637
Mailing address:
  • Phone: 207-831-9127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN193467
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN-NP193467
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: