Provider Demographics
NPI:1275912065
Name:KENNARD, JENNIFER LASHELLE (DO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LASHELLE
Last Name:KENNARD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5540
Mailing Address - Fax:601-984-5535
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:DEPARTMENT OF MEDICINE
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5601
Practice Address - Fax:601-984-6601
Is Sole Proprietor?:No
Enumeration Date:2015-05-26
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS26977207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00733373Medicaid