Provider Demographics
NPI:1457016602
Name:KENEALY, JEZABELLE ENRIQUEZ (MSOM, LAC)
Entity Type:Individual
Prefix:
First Name:JEZABELLE
Middle Name:ENRIQUEZ
Last Name:KENEALY
Suffix:
Gender:F
Credentials:MSOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 HILLTOP RD
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-2803
Mailing Address - Country:US
Mailing Address - Phone:407-454-2885
Mailing Address - Fax:
Practice Address - Street 1:28 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08837-3911
Practice Address - Country:US
Practice Address - Phone:407-454-2885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-03
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00155300171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist