Provider Demographics
NPI:1922615277
Name:HANNAH, KENDALL JORDAN
Entity Type:Individual
Prefix:MRS
First Name:KENDALL
Middle Name:JORDAN
Last Name:HANNAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KENDALL
Other - Middle Name:JORDAN
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:258 SW ROBINSON CT
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32024-4193
Mailing Address - Country:US
Mailing Address - Phone:386-590-3411
Mailing Address - Fax:
Practice Address - Street 1:1620 HELVENSTON ST SE
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:FL
Practice Address - Zip Code:32064-3474
Practice Address - Country:US
Practice Address - Phone:386-590-3411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA17867235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist