Healthcare Provider Details

I. General information

NPI: 1447391677
Provider Name (Legal Business Name): JASON DEWAYNE KENNEDY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 DESALES AVE
CHATTANOOGA TN
37404-1161
US

IV. Provider business mailing address

2525 DESALES AVE
CHATTANOOGA TN
37404-1161
US

V. Phone/Fax

Practice location:
  • Phone: 423-495-7404
  • Fax:
Mailing address:
  • Phone: 615-484-5316
  • Fax: 423-495-2625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number26161
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number46094
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number61105
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: