Healthcare Provider Details

I. General information

NPI: 1275904419
Provider Name (Legal Business Name): JILL KENNEDY PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2015
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 PHILLIPS ST
MASSENA NY
13662-2016
US

IV. Provider business mailing address

PO BOX 608
MALONE NY
12953-0608
US

V. Phone/Fax

Practice location:
  • Phone: 518-764-8076
  • Fax: 315-764-8079
Mailing address:
  • Phone: 518-651-2302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number403653
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number541605
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: