Basic Information
| Provider Information | |||||||||
| NPI: | 1174566681 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JARRELL | ||||||||
| FirstName: | KENDRA | ||||||||
| MiddleName: | CHRISTINE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7073 CLYO RD | ||||||||
| Address2: | |||||||||
| City: | CENTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454594816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374355857 | ||||||||
| FaxNumber: | 9379124960 | ||||||||
| Practice Location | |||||||||
| Address1: | 1049 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011032114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137391100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 06/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | NP-08619 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 3138107 | 05 | OH | MEDICAID |