Provider Demographics
NPI:1467719260
Name:KENNEDY, LINA JACKLYN (MD)
Entity Type:Individual
Prefix:DR
First Name:LINA
Middle Name:JACKLYN
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 E COAST HWY STE 280
Mailing Address - Street 2:
Mailing Address - City:CORONA DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92625-1940
Mailing Address - Country:US
Mailing Address - Phone:949-688-1288
Mailing Address - Fax:
Practice Address - Street 1:2121 E COAST HWY STE 280
Practice Address - Street 2:
Practice Address - City:CORONA DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92625-1940
Practice Address - Country:US
Practice Address - Phone:949-688-1288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-18
Last Update Date:2023-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA141381207NS0135X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program