Provider Demographics
NPI:1548823917
Name:KENNEDY, JENNIFER D (PSYD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:D
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5120 NUTHATCH CT NE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-4528
Mailing Address - Country:US
Mailing Address - Phone:360-890-0694
Mailing Address - Fax:
Practice Address - Street 1:5120 NUTHATCH CT NE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-4528
Practice Address - Country:US
Practice Address - Phone:360-890-0694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-20
Last Update Date:2019-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60869052103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical