Provider Demographics
NPI:1003829300
Name:KENNEDY, JAMIESON D (MD)
Entity Type:Individual
Prefix:
First Name:JAMIESON
Middle Name:D
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 W COLORADO AVE
Mailing Address - Street 2:STE 203
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80904
Mailing Address - Country:US
Mailing Address - Phone:719-473-2368
Mailing Address - Fax:719-473-4581
Practice Address - Street 1:2020 W COLORADO AVE
Practice Address - Street 2:STE 203
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80904
Practice Address - Country:US
Practice Address - Phone:719-473-2368
Practice Address - Fax:719-473-4581
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO14326207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01143262Medicaid
D22631Medicare UPIN
COC48701Medicare PIN