Provider Demographics
NPI:1043990229
Name:KENNINGTON, JEFFREY LYNN (RN)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:LYNN
Last Name:KENNINGTON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 LAMPASAS WAY
Mailing Address - Street 2:
Mailing Address - City:WAKE VILLAGE
Mailing Address - State:TX
Mailing Address - Zip Code:75501-5791
Mailing Address - Country:US
Mailing Address - Phone:903-293-1142
Mailing Address - Fax:
Practice Address - Street 1:510 E STONER AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4243
Practice Address - Country:US
Practice Address - Phone:318-221-8411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-21
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX790105163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine