Provider Demographics
NPI:1033809884
Name:KENNEY, JACQUELINE TAYLOR (OD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:TAYLOR
Last Name:KENNEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 HERRICK ST STE 102
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-2734
Mailing Address - Country:US
Mailing Address - Phone:978-338-4321
Mailing Address - Fax:978-927-1010
Practice Address - Street 1:77 HERRICK ST STE 102
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-2734
Practice Address - Country:US
Practice Address - Phone:978-338-4321
Practice Address - Fax:978-927-1010
Is Sole Proprietor?:No
Enumeration Date:2023-05-15
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAOPT5618152W00000X, 152WP0200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program