Provider Demographics
NPI:1649094715
Name:KENNEDY ADMINISTRATION
Entity type:Organization
Organization Name:KENNEDY ADMINISTRATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR /OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAJUAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:414-346-0276
Mailing Address - Street 1:3612 WEST NORTH AVENUE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53208
Mailing Address - Country:US
Mailing Address - Phone:414-346-0276
Mailing Address - Fax:414-600-6206
Practice Address - Street 1:3612 WEST NORTH AVENUE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208
Practice Address - Country:US
Practice Address - Phone:414-346-0276
Practice Address - Fax:414-600-6206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-14
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty