Provider Demographics
NPI:1528493368
Name:KENNEDY, JESSICA K (PA-C)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:K
Last Name:KENNEDY
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 1:3212 E 104TH AVE
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80233-4406
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3212 E 104TH AVE
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80233-4406
Practice Address - Country:US
Practice Address - Phone:303-861-7878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-12
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110004318363A00000X
COPA0004631363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant