Provider Demographics
NPI:1255489415
Name:KENDRICK, JACK JR (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:KENDRICK
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 280
Mailing Address - Street 2:
Mailing Address - City:PRESTONSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653-0280
Mailing Address - Country:US
Mailing Address - Phone:606-349-7474
Mailing Address - Fax:606-349-7737
Practice Address - Street 1:117 OAK RIDGE CT
Practice Address - Street 2:
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653-8607
Practice Address - Country:US
Practice Address - Phone:606-886-8109
Practice Address - Fax:606-886-9102
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-06
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY29774207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64297740Medicaid
KY010161400OtherFEDERAL BLACK LUNG
KY000000229925OtherANTHEM BLUE CROSS
KYP00047645OtherPALMETTO GBA
KY010161400OtherFEDERAL BLACK LUNG
KYP00047645OtherPALMETTO GBA