Provider Demographics
NPI:1841492568
Name:KENNEDY, KEVIN D (PT)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:D
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 N STATE ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-1689
Mailing Address - Country:US
Mailing Address - Phone:601-944-1717
Mailing Address - Fax:601-944-9780
Practice Address - Street 1:1200 N STATE ST
Practice Address - Street 2:SUITE 500
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2000
Practice Address - Country:US
Practice Address - Phone:601-352-2273
Practice Address - Fax:601-714-3415
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3757225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04139874Medicaid
MSP00410919OtherRR MEDICARE
MS650001179Medicare PIN