Provider Demographics
NPI:1922770528
Name:PERRY, KENNETH DEWAYNE
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:DEWAYNE
Last Name:PERRY
Suffix:
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 1:5905 AIRWAYS BLVD BLDG 231-5
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-1921
Mailing Address - Country:US
Mailing Address - Phone:901-650-6801
Mailing Address - Fax:
Practice Address - Street 1:112 N LIBERTY ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-6200
Practice Address - Country:US
Practice Address - Phone:731-736-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-01
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12703101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional