Healthcare Provider Details

I. General information

NPI: 1700923703
Provider Name (Legal Business Name): ROBERT W KENNON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 12/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 TUCKER ST
JACKSON TN
38301-4035
US

IV. Provider business mailing address

106 TUCKER ST
JACKSON TN
38301-4035
US

V. Phone/Fax

Practice location:
  • Phone: 731-427-1740
  • Fax: 731-427-1436
Mailing address:
  • Phone: 731-427-1740
  • Fax: 731-427-1436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberP0000001493
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberP0000001493
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: