Provider Demographics
NPI:1063109817
Name:KENNEDY, JAMES C JR (PHD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:C
Last Name:KENNEDY
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:1190 N HIGHLAND AVE NE # 8471
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30306-4051
Mailing Address - Country:US
Mailing Address - Phone:470-398-1919
Mailing Address - Fax:
Practice Address - Street 1:1190 N HIGHLAND AVE NE # 8471
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30306-4051
Practice Address - Country:US
Practice Address - Phone:470-398-1919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-21
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY004652103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical