Basic Information
| Provider Information | |||||||||
| NPI: | 1255489415 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KENDRICK | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 280 | ||||||||
| Address2: | |||||||||
| City: | PRESTONSBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 416530280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063497474 | ||||||||
| FaxNumber: | 6063497737 | ||||||||
| Practice Location | |||||||||
| Address1: | 117 OAK RIDGE CT | ||||||||
| Address2: | |||||||||
| City: | PRESTONSBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 416538607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068868109 | ||||||||
| FaxNumber: | 6068869102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2007 | ||||||||
| LastUpdateDate: | 03/05/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 29774 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64297740 | 05 | KY | MEDICAID | 010161400 | 01 | KY | FEDERAL BLACK LUNG | OTHER | 000000229925 | 01 | KY | ANTHEM BLUE CROSS | OTHER | P00047645 | 01 | KY | PALMETTO GBA | OTHER |