Healthcare Provider Details

I. General information

NPI: 1730719048
Provider Name (Legal Business Name): JESSICA CATHERINE KENNEDY LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2020
Last Update Date: 05/17/2026
Certification Date: 05/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 DANIEL MILL XING
VILLA RICA GA
30180-5156
US

IV. Provider business mailing address

313 DANIEL MILL XING
VILLA RICA GA
30180-5156
US

V. Phone/Fax

Practice location:
  • Phone: 678-590-9574
  • Fax:
Mailing address:
  • Phone: 678-590-9574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC016832
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: