Provider Demographics
NPI:1649660408
Name:KENNEDY, JILL (MCP, LPC)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MCP, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2025 S VAN BUREN ST
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-8214
Mailing Address - Country:US
Mailing Address - Phone:580-341-0899
Mailing Address - Fax:
Practice Address - Street 1:1625 W OWEN K GARRIOTT RD STE F
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-5653
Practice Address - Country:US
Practice Address - Phone:580-242-4673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4169101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor