Provider Demographics
NPI:1295106409
Name:KENNER, MELISSA (LCSW, LMSW)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:KENNER
Suffix:
Gender:F
Credentials:LCSW, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 WELLS RD STE 300
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-2982
Mailing Address - Country:US
Mailing Address - Phone:904-282-6331
Mailing Address - Fax:904-619-1080
Practice Address - Street 1:1865 LIME ST STE 100
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-4779
Practice Address - Country:US
Practice Address - Phone:904-321-8400
Practice Address - Fax:904-321-8401
Is Sole Proprietor?:No
Enumeration Date:2015-10-14
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW0070821041C0700X
FLSW151411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical