Provider Demographics
NPI:1649369141
Name:REED, KENNETH J (PAC)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:REED
Suffix:
Gender:M
Credentials:PAC
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 447
Mailing Address - Street 2:
Mailing Address - City:JELLICO
Mailing Address - State:TN
Mailing Address - Zip Code:37762-0447
Mailing Address - Country:US
Mailing Address - Phone:423-784-7269
Mailing Address - Fax:423-784-3708
Practice Address - Street 1:131 HOSPITAL LN
Practice Address - Street 2:
Practice Address - City:JELLICO
Practice Address - State:TN
Practice Address - Zip Code:37762-4404
Practice Address - Country:US
Practice Address - Phone:423-784-7269
Practice Address - Fax:423-784-3708
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA0000000105363AM0700X
KYPA272363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1522588Medicaid
TN1522588Medicaid
TN3665889Medicare ID - Type Unspecified
KY95000196Medicaid
TN3665889Medicare ID - Type Unspecified