Healthcare Provider Details

I. General information

NPI: 1417334129
Provider Name (Legal Business Name): JESSICA KENNEN CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2015
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST
BOSTON MA
02114-2621
US

IV. Provider business mailing address

185 PAXTON RD
SPENCER MA
01562-1425
US

V. Phone/Fax

Practice location:
  • Phone: 617-643-9079
  • Fax:
Mailing address:
  • Phone: 508-768-8610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number269798
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number269798
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number269798
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: