Provider Demographics
NPI:1609877653
Name:KENNEDY, JACQUELINE F (FNP)
Entity type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:F
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MS
Other - First Name:JACQUELINE
Other - Middle Name:F
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:P.O. BOX 205
Mailing Address - Street 2:
Mailing Address - City:WHATELY
Mailing Address - State:MA
Mailing Address - Zip Code:01093
Mailing Address - Country:US
Mailing Address - Phone:413-665-0176
Mailing Address - Fax:413-397-9760
Practice Address - Street 1:181 STATE RD
Practice Address - Street 2:
Practice Address - City:WHATELY
Practice Address - State:MA
Practice Address - Zip Code:01093
Practice Address - Country:US
Practice Address - Phone:413-665-0176
Practice Address - Fax:413-665-0176
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA169562363LF0000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Not Answered363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9709444Medicaid
MA0380890Medicaid
NP2260Medicare ID - Type Unspecified
MA9709444Medicaid