Provider Demographics
NPI:1679792071
Name:KENNEDY, JANE E (NP)
Entity Type:Individual
Prefix:MS
First Name:JANE
Middle Name:E
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2455 BENNETT VALLEY RD STE B205
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-5667
Mailing Address - Country:US
Mailing Address - Phone:707-536-9722
Mailing Address - Fax:707-843-5475
Practice Address - Street 1:2455 BENNETT VALLEY RD STE B205
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-5667
Practice Address - Country:US
Practice Address - Phone:707-536-9722
Practice Address - Fax:707-843-5475
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13881363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner