Provider Demographics
NPI:1881667616
Name:KLEIN, KENEDI JASON (LCSW)
Entity Type:Individual
Prefix:MR
First Name:KENEDI
Middle Name:JASON
Last Name:KLEIN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 STEEPLECHASE RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-7206
Mailing Address - Country:US
Mailing Address - Phone:910-547-5063
Mailing Address - Fax:
Practice Address - Street 1:1008 STEEPLECHASE RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-7206
Practice Address - Country:US
Practice Address - Phone:910-547-5063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0050741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6007241Medicaid