Healthcare Provider Details

I. General information

NPI: 1881647691
Provider Name (Legal Business Name): JARREL KENYATTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 DIANA DR
WEBSTER SPRINGS WV
26288-9078
US

IV. Provider business mailing address

125 DIANA DR
WEBSTER SPRINGS WV
26288-9078
US

V. Phone/Fax

Practice location:
  • Phone: 304-847-5682
  • Fax: 301-874-5401
Mailing address:
  • Phone: 304-847-5682
  • Fax: 301-874-5401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number23910
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code146D00000X
TaxonomyPersonal Emergency Response Attendant
License NumberMD419350
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: