Provider Demographics
NPI:1790551125
Name:KENDJELIC, KATHRYN JEAN (ISW)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:JEAN
Last Name:KENDJELIC
Suffix:
Gender:F
Credentials:ISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4263 LOSCO RD APT 523
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-1450
Mailing Address - Country:US
Mailing Address - Phone:937-305-4380
Mailing Address - Fax:
Practice Address - Street 1:11555 CENTRAL PKWY STE 701
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-2699
Practice Address - Country:US
Practice Address - Phone:937-305-4380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-27
Last Update Date:2023-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW194561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical