Provider Demographics
NPI:1275776809
Name:KENNEY, JAYNELLE H (LCSW)
Entity Type:Individual
Prefix:
First Name:JAYNELLE
Middle Name:H
Last Name:KENNEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:847 PARKCENTRE WAY STE 4
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-1794
Mailing Address - Country:US
Mailing Address - Phone:208-353-8973
Mailing Address - Fax:
Practice Address - Street 1:847 PARKCENTRE WAY STE 4
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-1794
Practice Address - Country:US
Practice Address - Phone:208-353-8973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-13
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-27480101Y00000X
IDLCSW-309861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807366600Medicaid