Provider Demographics
NPI:1821076043
Name:KENNEDY, JAY MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:MICHAEL
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 1:808 DIAMOND ST
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:PA
Mailing Address - Zip Code:15530-1539
Mailing Address - Country:US
Mailing Address - Phone:814-267-5830
Mailing Address - Fax:814-267-6103
Practice Address - Street 1:808 DIAMOND ST
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:PA
Practice Address - Zip Code:15530-1539
Practice Address - Country:US
Practice Address - Phone:814-267-5830
Practice Address - Fax:814-267-6103
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-06
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC003949L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA216978OtherUPMC
PA93492Medicaid
PA2058294OtherAETNA HMO/POS
PA01162738Medicaid
PA1508429Medicaid
PA4281751OtherAETNA PPO
PABA1489298OtherBCBS
PAKE469395OtherBCBS
PA93492Medicaid
PA01162738Medicaid