Provider Demographics
NPI:1407976079
Name:KENNISON, BARBARA JEAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:BARBARA
Middle Name:JEAN
Last Name:KENNISON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:697 HANNAH AVE
Mailing Address - Street 2:P.O. BOX 6416
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-3399
Mailing Address - Country:US
Mailing Address - Phone:231-947-5103
Mailing Address - Fax:231-929-1038
Practice Address - Street 1:697 HANNAH AVE
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3399
Practice Address - Country:US
Practice Address - Phone:231-947-5103
Practice Address - Fax:231-929-1038
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704091608163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M86780Medicare ID - Type UnspecifiedAPRN-BC