Provider Demographics
NPI:1972297471
Name:KIDDER, JAYNE PENELOPE (MA)
Entity Type:Individual
Prefix:
First Name:JAYNE
Middle Name:PENELOPE
Last Name:KIDDER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:J.
Other - Middle Name:PENELOPE
Other - Last Name:KIDDER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPCC-S
Mailing Address - Street 1:127 WOODSIDE AVE SE
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-3236
Mailing Address - Country:US
Mailing Address - Phone:513-509-2579
Mailing Address - Fax:234-209-9010
Practice Address - Street 1:127 WOODSIDE AVE SE
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-3236
Practice Address - Country:US
Practice Address - Phone:513-509-2579
Practice Address - Fax:234-209-9010
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-07
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0002003101YA0400X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health