Healthcare Provider Details

I. General information

NPI: 1841492568
Provider Name (Legal Business Name): KEVIN D KENNEDY PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 09/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N STATE ST SUITE 500
JACKSON MS
39202-2000
US

IV. Provider business mailing address

1600 N STATE ST SUITE 400
JACKSON MS
39202-1689
US

V. Phone/Fax

Practice location:
  • Phone: 601-352-2273
  • Fax: 601-714-3415
Mailing address:
  • Phone: 601-944-1717
  • Fax: 601-944-9780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT3757
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: