Provider Demographics
NPI:1215278643
Name:KENNEBREW, JACQUELINE ELAINE (RN)
Entity type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:ELAINE
Last Name:KENNEBREW
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7500 BROOKFIELD RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-2206
Mailing Address - Country:US
Mailing Address - Phone:803-699-2800
Mailing Address - Fax:803-419-0294
Practice Address - Street 1:7500 BROOKFIELD RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-2206
Practice Address - Country:US
Practice Address - Phone:803-699-2800
Practice Address - Fax:803-419-0294
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-11
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCR66767163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool