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General NPI Number Information
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NPI Number | 1013936962
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Entity Type | Individual
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Provider Name | JENNIFER A KENNEDY DDS
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Gender | Female
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Dates
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Enumeration Date | 07/19/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 601 BROADWAY AVE
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City | MATTOON
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State | IL
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Zip | 61938-4340
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Country | US
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Telephone | 217-235-0556
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Fax |
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Provider Business Mailing Address
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Address Line | 2544 NORTH COUNTY ROAD 1800 EAST
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City | CHARLESTON
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State | IL
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Zip | 61920
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Country | US
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Telephone | 217-345-3937
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State | IL
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