Provider Demographics
NPI:1528022779
Name:KENNEDY, JEREMY SCOTT (DO)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:SCOTT
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:13943 N 91 AVENUE
Mailing Address - Street 2:C-101
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-3629
Mailing Address - Country:US
Mailing Address - Phone:623-760-9449
Mailing Address - Fax:613-974-9351
Practice Address - Street 1:14506 W GRANITE VALLEY DR
Practice Address - Street 2:#124
Practice Address - City:SUN CITY WEST
Practice Address - State:AZ
Practice Address - Zip Code:85375-6010
Practice Address - Country:US
Practice Address - Phone:623-584-2127
Practice Address - Fax:623-854-1257
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ5839207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
4Z8735OtherHEALTH NET
AZ3437670OtherUNITED HEALTHCARE
AZ9558781OtherAETNA
AZ1528022779OtherBLUE CROSS BLUE SHIELD
AZ707257OtherAHCCCS
AZ707257Medicaid
AZP01043135OtherRAILROAD MEDICARE
AZ707257Medicaid