Provider Demographics
NPI:1124579776
Name:KENNEDY, GEORGE JR
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:KENNEDY
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 BIS RD SW
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-9606
Mailing Address - Country:US
Mailing Address - Phone:740-653-4324
Mailing Address - Fax:
Practice Address - Street 1:5900 BIS RD SW
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-9606
Practice Address - Country:US
Practice Address - Phone:740-653-4324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH021254101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)