Provider Demographics
NPI:1477256428
Name:KENNEDY-JOHNSON, KELLY (LPCC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KENNEDY-JOHNSON
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55118-2063
Mailing Address - Country:US
Mailing Address - Phone:320-241-7799
Mailing Address - Fax:
Practice Address - Street 1:15489 45TH ST S
Practice Address - Street 2:
Practice Address - City:AFTON
Practice Address - State:MN
Practice Address - Zip Code:55001-9681
Practice Address - Country:US
Practice Address - Phone:612-367-6046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC03678101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health