Healthcare Provider Details

I. General information

NPI: 1235619313
Provider Name (Legal Business Name): JENNIFER KEHOE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2018
Last Update Date: 08/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CHARLES EWING BLVD STE 160
EWING NJ
08628-3456
US

IV. Provider business mailing address

55 HATCHETTS HILL RD
OLD LYME CT
06371-1534
US

V. Phone/Fax

Practice location:
  • Phone: 800-370-3651
  • Fax:
Mailing address:
  • Phone: 800-370-3651
  • Fax: 877-515-7147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number35SI00598100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: