Healthcare Provider Details

I. General information

NPI: 1083478606
Provider Name (Legal Business Name): KENNEDY JORDAHL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2024
Last Update Date: 02/13/2026
Certification Date: 02/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2061 HIGHWAY 52
MONCKS CORNER SC
29461-5017
US

IV. Provider business mailing address

2061 HIGHWAY 52
MONCKS CORNER SC
29461-5017
US

V. Phone/Fax

Practice location:
  • Phone: 843-761-8824
  • Fax:
Mailing address:
  • Phone: 843-761-8800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: