Provider Demographics
NPI:1568835387
Name:KENNEDY BEHAVIORAL HEALTH CENTER, LLC
Entity Type:Organization
Organization Name:KENNEDY BEHAVIORAL HEALTH CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-597-4979
Mailing Address - Street 1:3649 DOLOROSO LOOP RD
Mailing Address - Street 2:
Mailing Address - City:WOODVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39669-3805
Mailing Address - Country:US
Mailing Address - Phone:601-597-4979
Mailing Address - Fax:
Practice Address - Street 1:2420 TERRY RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-5754
Practice Address - Country:US
Practice Address - Phone:601-597-4979
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-02
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health