Healthcare Provider Details

I. General information

NPI: 1073532032
Provider Name (Legal Business Name): JACK NEIL KENDRICK CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

488 KENNESAW AVE NW STE 100
MARIETTA GA
30060-9409
US

IV. Provider business mailing address

10 GLENLAKE PKWY STE 900
ATLANTA GA
30328-7249
US

V. Phone/Fax

Practice location:
  • Phone: 404-888-7590
  • Fax:
Mailing address:
  • Phone: 404-888-7590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN-CRNA123295
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPN.APRN18085
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN192749
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: