MEDICARE: KATELYN A KENNON LSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker		IL

General Provider Information

NPI Number	:	1073335212
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATELYN A KENNON LSW

Provider Business Mailing Address
First Line	:	825 CHICAGO AVE FL 2A
Second Line	:
City	:	EVANSTON
State	:	IL
Zip	:	60202-2375
Country	:	US
Telephone Number	:	815-236-0274
Fax Number	:

Provider Business Practice Location Address
First Line	:	825 CHICAGO AVE FL 2A
Second Line	:
City	:	EVANSTON
State	:	IL
Zip	:	60202-2375
Country	:	US
Telephone Number	:	815-236-0274
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/29/2024
Last Update Date	:	10/29/2024

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