Provider Demographics
NPI:1154313344
Name:KENNEDY, GERALD RICHARD JR (DC)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:RICHARD
Last Name:KENNEDY
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 N 10TH ST
Mailing Address - Street 2:
Mailing Address - City:OOSTBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53070-1181
Mailing Address - Country:US
Mailing Address - Phone:920-564-6653
Mailing Address - Fax:
Practice Address - Street 1:28 N 10TH ST
Practice Address - Street 2:
Practice Address - City:OOSTBURG
Practice Address - State:WI
Practice Address - Zip Code:53070-1181
Practice Address - Country:US
Practice Address - Phone:920-564-6653
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2099012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI75948Medicare ID - Type Unspecified