Provider Demographics
NPI:1295921351
Name:KENNEDY HERRMANN, JESSICA L (LCSW, LCAC)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:L
Last Name:KENNEDY HERRMANN
Suffix:
Gender:F
Credentials:LCSW, LCAC
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Mailing Address - Street 1:9111 BROADWAY
Mailing Address - Street 2:BROADFIELD CENTER SUITE N
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-8122
Mailing Address - Country:US
Mailing Address - Phone:219-791-1006
Mailing Address - Fax:219-791-1007
Practice Address - Street 1:9111 BROADWAY
Practice Address - Street 2:BROADFIELD CENTER SUITE N
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-8122
Practice Address - Country:US
Practice Address - Phone:219-791-1006
Practice Address - Fax:219-791-1007
Is Sole Proprietor?:No
Enumeration Date:2007-09-21
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN877001276A101YA0400X
IN34006146A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200264420OtherGROUP MEDICAID