Provider Demographics
NPI:1528022779
Name:KENNEDY, JEREMY SCOTT (DO)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:SCOTT
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 WATKINS CENTRE PKWY STE 350
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23114-4404
Mailing Address - Country:US
Mailing Address - Phone:804-464-8644
Mailing Address - Fax:804-464-8508
Practice Address - Street 1:611 WATKINS CENTRE PKWY STE 350
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23114-4404
Practice Address - Country:US
Practice Address - Phone:804-464-8644
Practice Address - Fax:804-464-8508
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2025-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102209089207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ9558781OtherAETNA
4Z8735OtherHEALTH NET
AZ707257OtherAHCCCS
AZP01043135OtherRAILROAD MEDICARE
AZ1528022779OtherBLUE CROSS BLUE SHIELD
AZ707257Medicaid
AZ3437670OtherUNITED HEALTHCARE
AZ707257Medicaid