Provider Demographics
NPI:1295490548
Name:KENNEDY, TIMOTHY JOSEPH
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JOSEPH
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 1:8839 COLUMBUS RD APT A
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050-4403
Mailing Address - Country:US
Mailing Address - Phone:740-501-2606
Mailing Address - Fax:
Practice Address - Street 1:8402 BLACKJACK RD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-9193
Practice Address - Country:US
Practice Address - Phone:740-397-0442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-02
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator