Provider Demographics
NPI:1013899772
Name:KENNEDY, JACK DYLAN (RD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:DYLAN
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1237 PINEHURST RD
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91915-1245
Mailing Address - Country:US
Mailing Address - Phone:619-917-9321
Mailing Address - Fax:
Practice Address - Street 1:1237 PINEHURST RD
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91915-1245
Practice Address - Country:US
Practice Address - Phone:619-917-9321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-23
Last Update Date:2025-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86296497133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered