Provider Demographics
NPI:1437512621
Name:KENNEDY, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 E PARK DR
Mailing Address - Street 2:
Mailing Address - City:BEULAVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28518-6916
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:124 E PARK DR
Practice Address - Street 2:
Practice Address - City:BEULAVILLE
Practice Address - State:NC
Practice Address - Zip Code:28518-6916
Practice Address - Country:US
Practice Address - Phone:888-258-6905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-04
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9743235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist