Provider Demographics
NPI:1417334129
Name:KENNEN, JESSICA (CPNP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:KENNEN
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 PAXTON RD
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:MA
Mailing Address - Zip Code:01562-1425
Mailing Address - Country:US
Mailing Address - Phone:508-768-8610
Mailing Address - Fax:
Practice Address - Street 1:10 WINTHROP ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01604-4435
Practice Address - Country:US
Practice Address - Phone:508-753-3120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-01
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA269798363LP0200X, 163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163WP0200XNursing Service ProvidersRegistered NursePediatrics