Basic Information
| Provider Information | |||||||||
| NPI: | 1588268320 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KENNEDY | ||||||||
| FirstName: | TEDI | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1325 E FORTIFICATION ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013544488 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1325 E FORTIFICATION ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013544488 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2020 | ||||||||
| LastUpdateDate: | 11/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 904292 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.