Provider Demographics
NPI:1730139098
Name:KENNEDY, JAN MARIE (CRNP)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:MARIE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:CRNP
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 5689
Mailing Address - Street 2:1813 BELTLINE RD SW
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-0689
Mailing Address - Country:US
Mailing Address - Phone:256-353-6874
Mailing Address - Fax:256-260-0594
Practice Address - Street 1:1813 BELTLINE RD SW
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-5506
Practice Address - Country:US
Practice Address - Phone:256-353-6874
Practice Address - Fax:256-260-0594
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1076407363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1-076407OtherALABAMA LICENSE
AL51533376OtherBCBS
AL1-076407OtherALABAMA LICENSE