Healthcare Provider Details

I. General information

NPI: 1720106743
Provider Name (Legal Business Name): KENDALL JASPER PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 04/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 W MOREHEAD ST
CHARLOTTE NC
28202-1521
US

IV. Provider business mailing address

223 W MOREHEAD ST
CHARLOTTE NC
28202-1521
US

V. Phone/Fax

Practice location:
  • Phone: 980-819-5692
  • Fax: 980-819-5694
Mailing address:
  • Phone: 980-819-5692
  • Fax: 980-819-5694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4088
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number4088
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number4088
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number4088
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: