Healthcare Provider Details

I. General information

NPI: 1477843514
Provider Name (Legal Business Name): JAMIE NICOLE KENNEDY LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2011
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4304 S BEARFIELD RD
COLUMBIA MO
65201-9557
US

IV. Provider business mailing address

360 SHADY GRV
NEW BLOOMFIELD MO
65063-1429
US

V. Phone/Fax

Practice location:
  • Phone: 573-874-8686
  • Fax: 573-874-8608
Mailing address:
  • Phone: 573-874-8686
  • Fax: 573-874-8608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2011008109
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: