Healthcare Provider Details

I. General information

NPI: 1518151935
Provider Name (Legal Business Name): JASON ROBERT KENNEDY D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2007
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 INDUSTRIAL PARK RD
ROCKY TOP TN
37769
US

IV. Provider business mailing address

110 INDUSTRIAL PARK RD
ROCKY TOP TN
37769
US

V. Phone/Fax

Practice location:
  • Phone: 865-498-6725
  • Fax: 865-498-9808
Mailing address:
  • Phone: 865-498-6725
  • Fax: 865-498-9808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberN/A (RESIDENT)
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: