Provider Demographics
NPI:1821146986
Name:EDMOND, JOHN KENNEDY SR
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:KENNEDY
Last Name:EDMOND
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1036 BRANCHVIEW DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2998
Mailing Address - Country:US
Mailing Address - Phone:704-793-9593
Mailing Address - Fax:704-795-0825
Practice Address - Street 1:1036 BRANCHVIEW DR
Practice Address - Street 2:SUITE 201
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2998
Practice Address - Country:US
Practice Address - Phone:704-793-9593
Practice Address - Fax:704-795-0825
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603176Medicaid
NC6603333Medicaid
NC6603560Medicaid