Healthcare Provider Details

I. General information

NPI: 1497951677
Provider Name (Legal Business Name): JERMAINE J KENNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 CENTRAL AVE
DUNKIRK NY
14048-2137
US

IV. Provider business mailing address

7 N ERIE ST
MAYVILLE NY
14757-1090
US

V. Phone/Fax

Practice location:
  • Phone: 716-363-3550
  • Fax:
Mailing address:
  • Phone: 716-753-4318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: