Provider Demographics
NPI:1275904419
Name:KENNEDY, JILL (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 SH 310 STE 1
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617-1493
Mailing Address - Country:US
Mailing Address - Phone:315-386-2167
Mailing Address - Fax:
Practice Address - Street 1:80 SH 310 STE 1
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-1493
Practice Address - Country:US
Practice Address - Phone:315-386-2167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-14
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY541605163W00000X
NY403653363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse