Provider Demographics
NPI:1376379453
Name:KENNINGTON, JORDAN BLADE
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:BLADE
Last Name:KENNINGTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:362 RANSON RD
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:SC
Mailing Address - Zip Code:29720-8764
Mailing Address - Country:US
Mailing Address - Phone:478-258-3346
Mailing Address - Fax:
Practice Address - Street 1:1420 EBENEZER RD STE 101
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-2774
Practice Address - Country:US
Practice Address - Phone:704-981-1558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-13
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9278101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional