Provider Demographics
NPI:1093569709
Name:JERNIGAN, KANDIS
Entity Type:Individual
Prefix:
First Name:KANDIS
Middle Name:
Last Name:JERNIGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 MUSKEGON AVE
Mailing Address - Street 2:
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-2348
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5600 RICKENBACKER RD BLDG 2AB
Practice Address - Street 2:
Practice Address - City:BELL
Practice Address - State:CA
Practice Address - Zip Code:90201-6418
Practice Address - Country:US
Practice Address - Phone:323-263-1206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-17
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health