Provider Demographics
NPI:1386235802
Name:KENNEBREW, KEANDRE JAMAAL
Entity type:Individual
Prefix:
First Name:KEANDRE
Middle Name:JAMAAL
Last Name:KENNEBREW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1665 RIVA RIDGE DR APT 1
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44904-2007
Mailing Address - Country:US
Mailing Address - Phone:567-241-6387
Mailing Address - Fax:
Practice Address - Street 1:1033 LARCHWOOD RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44907-2424
Practice Address - Country:US
Practice Address - Phone:419-747-4122
Practice Address - Fax:419-747-4126
Is Sole Proprietor?:No
Enumeration Date:2021-01-27
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician