Provider Demographics
NPI:1780716258
Name:KENNRIDGE PSYCHOLOGICAL ASSOCIATES
Entity type:Organization
Organization Name:KENNRIDGE PSYCHOLOGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:A
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:770-956-9213
Mailing Address - Street 1:6065 ROSWELL RD
Mailing Address - Street 2:SUITE 725
Mailing Address - City:SANDY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30328-4043
Mailing Address - Country:US
Mailing Address - Phone:770-956-9213
Mailing Address - Fax:770-956-9218
Practice Address - Street 1:6065 ROSWELL ROAD
Practice Address - Street 2:SUITE 725
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30328-4043
Practice Address - Country:US
Practice Address - Phone:770-956-9213
Practice Address - Fax:770-956-9218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-11
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1582103T00000X
GA818106H00000X
GA3552103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty