Provider Demographics
NPI:1194157305
Name:KENNEDY, JACQUELYN CORDELIA
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:CORDELIA
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3403 OAKMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48238-4201
Mailing Address - Country:US
Mailing Address - Phone:248-905-3967
Mailing Address - Fax:
Practice Address - Street 1:3403 OAKMAN BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48238-4201
Practice Address - Country:US
Practice Address - Phone:248-905-3967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-30
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst