Provider Demographics
NPI:1750768263
Name:KENNEDY, JESSICA LYNN (DDS)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:LYNN
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:JESSICA
Other - Middle Name:LYNN
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:3801 KERN RD
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902
Mailing Address - Country:US
Mailing Address - Phone:509-574-3220
Mailing Address - Fax:509-574-3211
Practice Address - Street 1:3801 KERN RD
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902
Practice Address - Country:US
Practice Address - Phone:509-574-3220
Practice Address - Fax:509-574-3211
Is Sole Proprietor?:No
Enumeration Date:2015-05-04
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13801122300000X, 1223P0221X
WARR60541536390200000X
WADE607914721223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program