Healthcare Provider Details

I. General information

NPI: 1093843971
Provider Name (Legal Business Name): TERRI KENNEDY-JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 06/06/2022
Certification Date: 06/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4211 AVALON BLVD
LOS ANGELES CA
90011-5622
US

IV. Provider business mailing address

4211 AVALON BLVD
LOS ANGELES CA
90011-5622
US

V. Phone/Fax

Practice location:
  • Phone: 323-233-0425
  • Fax: 323-232-2366
Mailing address:
  • Phone: 323-233-0425
  • Fax: 323-232-2366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number131390
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: