Healthcare Provider Details

I. General information

NPI: 1912063736
Provider Name (Legal Business Name): JAN L KENNEDY LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 06/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 W MAIN ST SUITE A
NEW MARKET MD
21774-6279
US

IV. Provider business mailing address

164 W MAIN ST SUITE A
NEW MARKET MD
21774-6279
US

V. Phone/Fax

Practice location:
  • Phone: 240-285-5285
  • Fax:
Mailing address:
  • Phone: 240-285-5285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12832
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: