Provider Demographics
NPI:1285399832
Name:KENNEDY, JANELLE LESLIE (RD, LD)
Entity type:Individual
Prefix:
First Name:JANELLE
Middle Name:LESLIE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:MISS
Other - First Name:JANELLE
Other - Middle Name:LESLIE
Other - Last Name:BAILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:9665 S 150 W
Mailing Address - Street 2:
Mailing Address - City:BROOKSTON
Mailing Address - State:IN
Mailing Address - Zip Code:47923-8060
Mailing Address - Country:US
Mailing Address - Phone:765-430-0892
Mailing Address - Fax:
Practice Address - Street 1:9665 S 150 W
Practice Address - Street 2:
Practice Address - City:BROOKSTON
Practice Address - State:IN
Practice Address - Zip Code:47923-8060
Practice Address - Country:US
Practice Address - Phone:765-430-0892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-08
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37001384A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered