Provider Demographics
NPI:1245072784
Name:KENNEDY, FREDRICK DONIAL JR (PTA)
Entity type:Individual
Prefix:
First Name:FREDRICK
Middle Name:DONIAL
Last Name:KENNEDY
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6888 FRIARS RD APT 219
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-1168
Mailing Address - Country:US
Mailing Address - Phone:229-299-1533
Mailing Address - Fax:
Practice Address - Street 1:2650 CAMINO DEL RIO N STE 201
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-1631
Practice Address - Country:US
Practice Address - Phone:619-340-2096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-06
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53236225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant