Provider Demographics
NPI:1811301898
Name:KENNEY, JACQUELINE ELYCE (PA-C)
Entity type:Individual
Prefix:MISS
First Name:JACQUELINE
Middle Name:ELYCE
Last Name:KENNEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 NORTH HILLHURST AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-2003
Mailing Address - Country:US
Mailing Address - Phone:323-664-2931
Mailing Address - Fax:323-664-8931
Practice Address - Street 1:2101 NORTH HILLHURST AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-2003
Practice Address - Country:US
Practice Address - Phone:323-664-2931
Practice Address - Fax:323-664-8931
Is Sole Proprietor?:No
Enumeration Date:2014-06-17
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51586207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA51586OtherCA STATE LICENSE