Provider Demographics
NPI:1831679190
Name:KENNEDY, CATHERINE
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CATHERINE
Other - Middle Name:
Other - Last Name:KENNEDY JACOBS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 856
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:IL
Mailing Address - Zip Code:60002-0856
Mailing Address - Country:US
Mailing Address - Phone:847-903-5604
Mailing Address - Fax:224-788-5112
Practice Address - Street 1:800 MAIN ST STE 210
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:IL
Practice Address - Zip Code:60002
Practice Address - Country:US
Practice Address - Phone:847-903-5604
Practice Address - Fax:224-788-5112
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-16
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490035511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical