Healthcare Provider Details

I. General information

NPI: 1013626035
Provider Name (Legal Business Name): ALEXANDRA JANE KENNEDY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ALEXANDRA JANE WHEELER

II. Dates (important events)

Enumeration Date: 11/17/2022
Last Update Date: 11/17/2022
Certification Date: 11/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 WASHINGTON ST
MEDFORD MA
02155-4728
US

IV. Provider business mailing address

16 ISLAND HILL AVE UNIT 104
MELROSE MA
02176-6141
US

V. Phone/Fax

Practice location:
  • Phone: 413-464-3067
  • Fax:
Mailing address:
  • Phone: 413-464-3067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number228756
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number228756
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: