Healthcare Provider Details

I. General information

NPI: 1952863078
Provider Name (Legal Business Name): JESSICA RENE' KENNEDY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2019
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 E HIGHWAY 33
PERKINS OK
74059-4129
US

IV. Provider business mailing address

PO BOX 460
PERKINS OK
74059-0460
US

V. Phone/Fax

Practice location:
  • Phone: 405-547-2473
  • Fax: 405-547-2925
Mailing address:
  • Phone: 405-547-2473
  • Fax: 405-547-2925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number87596
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: