Provider Demographics
NPI:1730497918
Name:KENNEDY, JACKIE
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 EMBARCADERO CTR STE 1900
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94111-3723
Mailing Address - Country:US
Mailing Address - Phone:415-658-6791
Mailing Address - Fax:
Practice Address - Street 1:1350 CONNECTICUT AVE NW STE 1250
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20036-1728
Practice Address - Country:US
Practice Address - Phone:888-663-6331
Practice Address - Fax:415-252-7176
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-21
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10296363A00000X
MD1093616363A00000X
NC0010-11122363A00000X
VA0110-007135363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant