Healthcare Provider Details

I. General information

NPI: 1194504613
Provider Name (Legal Business Name): KENDRA MARIE JUDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KENDRA COLLETT

II. Dates (important events)

Enumeration Date: 09/25/2023
Last Update Date: 09/25/2023
Certification Date: 09/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 S LAKE DR
PRESTONSBURG KY
41653-1339
US

IV. Provider business mailing address

631 S LAKE DR
PRESTONSBURG KY
41653-1339
US

V. Phone/Fax

Practice location:
  • Phone: 606-430-2256
  • Fax:
Mailing address:
  • Phone: 606-430-2256
  • Fax: 606-218-6577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-293151
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: