Provider Demographics
NPI:1013494897
Name:PSYCHODYNAMICS PROFESSIONAL LLC
Entity Type:Organization
Organization Name:PSYCHODYNAMICS PROFESSIONAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER AND MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-255-7672
Mailing Address - Street 1:PO BOX 634
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81502-0634
Mailing Address - Country:US
Mailing Address - Phone:970-255-7672
Mailing Address - Fax:
Practice Address - Street 1:2501 BLICHMANN AVENUE
Practice Address - Street 2:SUITE 115
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81505
Practice Address - Country:US
Practice Address - Phone:970-255-7672
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO357882084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty