Provider Demographics
NPI:1992782122
Name:KENNEDY, JACOB H (MD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:H
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3407
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47733-3407
Mailing Address - Country:US
Mailing Address - Phone:812-450-6815
Mailing Address - Fax:812-450-6822
Practice Address - Street 1:600 MARY ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47747-0001
Practice Address - Country:US
Practice Address - Phone:812-450-3405
Practice Address - Fax:812-450-3099
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-49394207P00000X
IN01056432A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000502888OtherBCBS - DEACONESS GATEWAY
KY64130222Medicaid
IN200423240Medicaid
IN000000502241OtherBCBS - DEACONESS MARY ST
INP00397501OtherRR MEDICARE
KY64130222Medicaid
H55515Medicare UPIN
IN534980OOOMedicare PIN