Provider Demographics
NPI:1598855710
Name:KENNARD, JENNIFER MICHALEC (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MICHALEC
Last Name:KENNARD
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-1166
Mailing Address - Fax:704-384-1181
Practice Address - Street 1:11840 SOUTHMORE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-4466
Practice Address - Country:US
Practice Address - Phone:704-384-1166
Practice Address - Fax:704-384-1181
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2011-000732080N0001X, 208000000X
SC289202080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5918767Medicaid
SC289208Medicaid
SC289208Medicaid