Provider Demographics
NPI:1013087063
Name:KENNEDY, JOSEPH A (OTHER)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:A
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:OTHER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 MILES ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN BOW
Mailing Address - State:OK
Mailing Address - Zip Code:74728-4507
Mailing Address - Country:US
Mailing Address - Phone:580-236-5261
Mailing Address - Fax:
Practice Address - Street 1:902 E LINCOLN RD
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-7337
Practice Address - Country:US
Practice Address - Phone:580-286-2600
Practice Address - Fax:580-286-1107
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1117225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1117OtherPHYSICAL THERAPY
OK4463OtherOKLAHOMA PT LICENSE