Healthcare Provider Details

I. General information

NPI: 1588268320
Provider Name (Legal Business Name): TEDI KENNEDY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2020
Last Update Date: 08/28/2025
Certification Date: 08/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 E FORTIFICATION ST
JACKSON MS
39202-2442
US

IV. Provider business mailing address

1211 S GLOSTER ST STE A
TUPELO MS
38801-6548
US

V. Phone/Fax

Practice location:
  • Phone: 601-354-4488
  • Fax:
Mailing address:
  • Phone: 662-767-4200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number904292
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: