Healthcare Provider Details

I. General information

NPI: 1174455059
Provider Name (Legal Business Name): KENNEDY PURCEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

476 RIVERSIDE AVE
JACKSONVILLE FL
32202-4912
US

IV. Provider business mailing address

476 RIVERSIDE AVE
JACKSONVILLE FL
32202-4912
US

V. Phone/Fax

Practice location:
  • Phone: 904-335-8631
  • Fax: 904-265-6831
Mailing address:
  • Phone: 904-335-8631
  • Fax: 904-265-6831

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberISW21627
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: