Provider Demographics
NPI:1700923703
Name:KENNON, ROBERT W (PHD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:KENNON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 TUCKER ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-4035
Mailing Address - Country:US
Mailing Address - Phone:731-427-1740
Mailing Address - Fax:731-427-1436
Practice Address - Street 1:106 TUCKER ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-4035
Practice Address - Country:US
Practice Address - Phone:731-427-1740
Practice Address - Fax:731-427-1436
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP0000001493103TF0200X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3683772Medicare ID - Type UnspecifiedPROVIDER NUMBER