Provider Demographics
NPI:1780206425
Name:KENNEY, JEANETTE ANN (LADC)
Entity type:Individual
Prefix:
First Name:JEANETTE
Middle Name:ANN
Last Name:KENNEY
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:JEANETTE
Other - Middle Name:A
Other - Last Name:BECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:44 OTIS ST
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-4420
Mailing Address - Country:US
Mailing Address - Phone:860-608-3404
Mailing Address - Fax:
Practice Address - Street 1:567 VAUXHALL STREET EXT
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-4330
Practice Address - Country:US
Practice Address - Phone:860-608-3404
Practice Address - Fax:860-889-2876
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-16
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001263101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty