Healthcare Provider Details

I. General information

NPI: 1497727275
Provider Name (Legal Business Name): JEANENE K KENNETT FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4049 S CAMPBELL AVE
SPRINGFIELD MO
65807-5303
US

IV. Provider business mailing address

4049 S CAMPBELL AVE
SPRINGFIELD MO
65807-5303
US

V. Phone/Fax

Practice location:
  • Phone: 417-890-5550
  • Fax: 417-889-6898
Mailing address:
  • Phone: 417-890-5550
  • Fax: 417-889-6898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number153070
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: