Provider Demographics
NPI:1225345077
Name:KENNEDY-BALL, JAYDE (PSD, LP)
Entity Type:Individual
Prefix:MRS
First Name:JAYDE
Middle Name:
Last Name:KENNEDY-BALL
Suffix:
Gender:F
Credentials:PSD, LP
Other - Prefix:
Other - First Name:JAYDE
Other - Middle Name:
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3181 SANDHILL RD
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-9425
Mailing Address - Country:US
Mailing Address - Phone:517-455-0258
Mailing Address - Fax:
Practice Address - Street 1:3181 SANDHILL RD
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:MI
Practice Address - Zip Code:48854-9425
Practice Address - Country:US
Practice Address - Phone:517-455-0258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-31
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MI6301016332103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health