Provider Demographics
NPI:1689096331
Name:KENAYA, JESSICA (MSN, RN, CPNP-PC)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:
Last Name:KENAYA
Suffix:
Gender:F
Credentials:MSN, RN, CPNP-PC
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:MANSOUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN, RN, CPNP-PC
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3555 W 13 MILE RD
Practice Address - Street 2:SUITE 605
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6710
Practice Address - Country:US
Practice Address - Phone:248-551-3302
Practice Address - Fax:248-551-1350
Is Sole Proprietor?:No
Enumeration Date:2014-01-15
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704267272363LP0200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics