Provider Demographics
NPI:1255922118
Name:KENNEDY, DERRICK
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:KENNEDY
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 1:1089 LEA DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-3746
Mailing Address - Country:US
Mailing Address - Phone:510-368-0651
Mailing Address - Fax:
Practice Address - Street 1:1089 LEA DR
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-3746
Practice Address - Country:US
Practice Address - Phone:510-368-0651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-02
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator