Provider Demographics
NPI:1356905434
Name:JEAN, KENLEY (RN)
Entity type:Individual
Prefix:MR
First Name:KENLEY
Middle Name:
Last Name:JEAN
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93201 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:CENTRAL ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11722-5229
Mailing Address - Country:US
Mailing Address - Phone:516-615-9151
Mailing Address - Fax:
Practice Address - Street 1:32 EASTPOND LN
Practice Address - Street 2:
Practice Address - City:EASTPORT
Practice Address - State:NY
Practice Address - Zip Code:11941-1303
Practice Address - Country:US
Practice Address - Phone:631-682-7812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-24
Last Update Date:2022-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY323520164W00000X
NY850058163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse