Provider Demographics
NPI:1497890420
Name:KENNEDY, BRADLEY J (DC)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:J
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:393 CROSSGATES BOULEVARD
Mailing Address - Street 2:SUITE B
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042
Mailing Address - Country:US
Mailing Address - Phone:601-824-4217
Mailing Address - Fax:601-824-4218
Practice Address - Street 1:393 CROSSGATES BOULEVARD
Practice Address - Street 2:SUITE B
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042
Practice Address - Country:US
Practice Address - Phone:601-824-4217
Practice Address - Fax:601-824-4218
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS947111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS742966779OtherTAX ID#
MS350000235Medicare ID - Type Unspecified
MSU67878Medicare UPIN