MEDICARE: MISS JACQUELINE ELYCE KENNEY PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	51586	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	51586	OTHER	CA	CA STATE LICENSE

General Provider Information

NPI Number	:	1811301898
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS JACQUELINE ELYCE KENNEY PA-C

Provider Business Mailing Address
First Line	:	2101 NORTH HILLHURST AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90027-2003
Country	:	US
Telephone Number	:	323-664-2931
Fax Number	:	323-664-8931

Provider Business Practice Location Address
First Line	:	2101 NORTH HILLHURST AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90027-2003
Country	:	US
Telephone Number	:	323-664-2931
Fax Number	:	323-664-8931

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/17/2014
Last Update Date	:	06/17/2014

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