Healthcare Provider Details

I. General information

NPI: 1689096331
Provider Name (Legal Business Name): JESSICA KENAYA MSN, RN, CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA MANSOUR MSN, RN, CPNP-PC

II. Dates (important events)

Enumeration Date: 01/15/2014
Last Update Date: 07/22/2022
Certification Date: 07/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3555 W 13 MILE RD SUITE 605
ROYAL OAK MI
48073-6710
US

IV. Provider business mailing address

26901 BEAUMONT BLVD STE 3D
SOUTHFIELD MI
48033-3849
US

V. Phone/Fax

Practice location:
  • Phone: 248-551-3302
  • Fax: 248-551-1350
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number4704267272
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704267272
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: