MEDICARE: JACQUELYN KENNEDY

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	103K00000X	Behavior Analyst
2	171M00000X	Case Manager/Care Coordinator
3	172A00000X	Driver

General Provider Information

NPI Number	:	1427405976
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELYN KENNEDY

Provider Business Mailing Address
First Line	:	16811 LAUDER ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48235-4037
Country	:	US
Telephone Number	:	313-273-2093
Fax Number	:

Provider Business Practice Location Address
First Line	:	16811 LAUDER ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48235-4037
Country	:	US
Telephone Number	:	313-273-2093
Fax Number	:

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

Provider Enumeration Date	:	05/14/2016
Last Update Date	:	05/14/2016

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Directions to “ JACQUELYN KENNEDY ” Practice Location

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