Provider Demographics
NPI:1912063736
Name:KENNEDY, JAN L (LCSW-C)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:L
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 W MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEW MARKET
Mailing Address - State:MD
Mailing Address - Zip Code:21774-6279
Mailing Address - Country:US
Mailing Address - Phone:240-285-5285
Mailing Address - Fax:
Practice Address - Street 1:164 W MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:NEW MARKET
Practice Address - State:MD
Practice Address - Zip Code:21774-6279
Practice Address - Country:US
Practice Address - Phone:240-285-5285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD128321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical