Provider Demographics
NPI:1659679652
Name:KENNEDY, JARON BEAU (MA, LP C)
Entity Type:Individual
Prefix:MR
First Name:JARON
Middle Name:BEAU
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:MA, LP C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 WILKINS CIRCLE
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-1336
Mailing Address - Country:US
Mailing Address - Phone:307-237-9583
Mailing Address - Fax:307-265-7277
Practice Address - Street 1:1430 WILKINS CIRCLE
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-1336
Practice Address - Country:US
Practice Address - Phone:307-237-9583
Practice Address - Fax:307-265-7277
Is Sole Proprietor?:No
Enumeration Date:2011-03-01
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLPC-1306101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor