Basic Information
| Provider Information | |||||||||
| NPI: | 1073532032 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KENDRICK | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | N. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 607 CARRINGTON PL | ||||||||
| Address2: | |||||||||
| City: | ARDEN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287048810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286069349 | ||||||||
| FaxNumber: | 8286812747 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | HENDERSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287925272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286812113 | ||||||||
| FaxNumber: | 8286812747 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 05/02/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 192749 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 18085 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | AN2258 | 05 | SC | MEDICAID |