Provider Demographics
NPI:1588769111
Name:KENNEDY, MARCIA J (LCSW)
Entity type:Individual
Prefix:MS
First Name:MARCIA
Middle Name:J
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:492 E. 13TH SUITE 107
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401
Mailing Address - Country:US
Mailing Address - Phone:541-338-3008
Mailing Address - Fax:541-686-0451
Practice Address - Street 1:492 E. 13TH SUITE 107
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401
Practice Address - Country:US
Practice Address - Phone:541-338-3008
Practice Address - Fax:541-686-0451
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL26151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR114633Medicare ID - Type Unspecified
OR114632Medicare ID - Type Unspecified