Individual
JAN C KENNEDY
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
2701 N DECATUR RD, PATHOLOGY DEPT, DECATUR, GA 30033-5918
(404) 501-1000
Mailing address
PO BOX 1457, BLUEFIELD, WV 24701-1457
Taxonomy
Speciality
Code
Description
License number
State
207ZP0102X
Anatomic Pathology & Clinical Pathology Physician
Primary
031046
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000429118K
—
GA
05
—
000429118L
—
GA
01
—
160113
BLUE CROSS BLUE SHIELD
GA
01
—
567752
BLUE CROSS BLUE SHIELD
GA
Enumeration date
06/17/2005
Last updated
09/17/2012
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