Provider Demographics
NPI:1235352931
Name:KENNEDY, JENNIFER (MSOTRL)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MSOTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 NASSAU ST
Mailing Address - Street 2:
Mailing Address - City:BELLMORE
Mailing Address - State:NY
Mailing Address - Zip Code:11710-4052
Mailing Address - Country:US
Mailing Address - Phone:516-782-2725
Mailing Address - Fax:
Practice Address - Street 1:201 I U WILLETS RD
Practice Address - Street 2:
Practice Address - City:ALBERTSON
Practice Address - State:NY
Practice Address - Zip Code:11507-1516
Practice Address - Country:US
Practice Address - Phone:516-739-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0127841225XN1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00274415Medicaid
NY00274415Medicaid