Healthcare Provider Details

I. General information

NPI: 1720545189
Provider Name (Legal Business Name): JOHN ATKINS KENNEDY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2019
Last Update Date: 02/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7200 BANCROFT AVE STE 267
OAKLAND CA
94605-2403
US

IV. Provider business mailing address

1849 CHANNING WAY
BERKELEY CA
94703-1760
US

V. Phone/Fax

Practice location:
  • Phone: 510-735-0864
  • Fax: 510-746-1196
Mailing address:
  • Phone: 510-549-0237
  • Fax: 510-549-0237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: