Provider Demographics
NPI:1447391677
Name:KENNEDY, JASON DEWAYNE (MD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:DEWAYNE
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 DESALES AVE
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404-1161
Mailing Address - Country:US
Mailing Address - Phone:615-484-5316
Mailing Address - Fax:423-495-2625
Practice Address - Street 1:2525 DESALES AVE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-1161
Practice Address - Country:US
Practice Address - Phone:423-495-7404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL26161207L00000X
TN46094207LC0200X
GA61105207LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009942537Medicaid
AL051540437OtherBLUE CROSS
AL009942536Medicaid
AL009942538Medicaid
AL051540445OtherBLUE CROSS
AL009942534Medicaid
AL051540446OtherBLUE CROSS
AL051540447OtherBLUE CROSS
AL009942536Medicaid