Provider Demographics
NPI:1780644401
Name:KENNEDY, JERONE DANUEL (MD)
Entity Type:Individual
Prefix:
First Name:JERONE
Middle Name:DANUEL
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 6TH AVE N
Mailing Address - Street 2:CENTRACARE CLINIC
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2735
Mailing Address - Country:US
Mailing Address - Phone:320-240-2829
Mailing Address - Fax:757-388-6116
Practice Address - Street 1:1200 6TH AVE N
Practice Address - Street 2:CENTRACARE CLINIC
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2735
Practice Address - Country:US
Practice Address - Phone:757-388-6115
Practice Address - Fax:757-388-6116
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101254590207T00000X
MN39807207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI53379020OtherWISCONSIN MEDICAL BOARD
MN39807OtherMINNESOTA BOARD OF MEDICINE
WI53379020OtherWISCONSIN MEDICAL BOARD