Provider Demographics
NPI:1164505293
Name:KENNEDY WADE, JULIE A (MED)
Entity Type:Individual
Prefix:MS
First Name:JULIE
Middle Name:A
Last Name:KENNEDY WADE
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1847 ROLLING HILLS STREET
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072
Mailing Address - Country:US
Mailing Address - Phone:405-928-2044
Mailing Address - Fax:405-928-2049
Practice Address - Street 1:1847 ROLLING HILLS ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-6707
Practice Address - Country:US
Practice Address - Phone:405-928-2044
Practice Address - Fax:405-928-2049
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK550101YP2500X
OK629106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist