Basic Information
| Provider Information | |||||||||
| NPI: | 1164405460 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENTSCHEL | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO, PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 SHIRCLIFF WAY | ||||||||
| Address2: | SUITE 724 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322044786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043087959 | ||||||||
| FaxNumber: | 9043087938 | ||||||||
| Practice Location | |||||||||
| Address1: | 4205 BELFORT RD STE 1100 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322165876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044506300 | ||||||||
| FaxNumber: | 9042815866 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2005 | ||||||||
| LastUpdateDate: | 07/29/2019 | ||||||||
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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 | 204R00000X | OS8644 | FL | N | Allopathic & Osteopathic Physicians | Electrodiagnostic Medicine | 2084N0400X | 057817 | GA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0600X | OS8644 | FL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology | 2084N0400X | OS8644 | FL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 2757087-00 | 05 | FL | MEDICAID | 275708700 | 05 | FL | MEDICAID | 212536998A | 05 | GA | MEDICAID | 212536998B | 05 | GA | MEDICAID |