Healthcare Provider Details

I. General information

NPI: 1114675022
Provider Name (Legal Business Name): JACQUELYN RENEE KINNEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2022
Last Update Date: 10/19/2024
Certification Date: 10/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 BERGEN ST
NEWARK NJ
07103-2425
US

IV. Provider business mailing address

140 BERGEN ST
NEWARK NJ
07103-2425
US

V. Phone/Fax

Practice location:
  • Phone: 973-972-5377
  • Fax:
Mailing address:
  • Phone: 973-972-1129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberP24-00760
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: