1609877653 NPI number — MS. JACQUELINE F KENNEDY FNP

Table of content: MS. JACQUELINE F KENNEDY FNP (NPI 1609877653)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609877653 NPI number — MS. JACQUELINE F KENNEDY FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KENNEDY
Provider First Name:
JACQUELINE
Provider Middle Name:
F
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KENNEDY
Provider Other First Name:
JACQUELINE
Provider Other Middle Name:
F
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1609877653
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 205
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHATELY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01093
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
413-665-0176
Provider Business Mailing Address Fax Number:
413-397-9760

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
181 STATE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHATELY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01093
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
413-665-0176
Provider Business Practice Location Address Fax Number:
413-665-0176
Provider Enumeration Date:
08/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  169562 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 363LP2300X , with the licence number: 169562 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9709444 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0380890 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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