Healthcare Provider Details

I. General information

NPI: 1861973083
Provider Name (Legal Business Name): SHA'JUAN KENNEDY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2018
Last Update Date: 12/12/2019
Certification Date: 12/12/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13035 W BLUEMOUND RD STE 100
BROOKFIELD WI
53005-8001
US

IV. Provider business mailing address

401 W MICHIGAN ST APT 412
MILWAUKEE WI
53203-2815
US

V. Phone/Fax

Practice location:
  • Phone: 262-408-1125
  • Fax:
Mailing address:
  • Phone: 414-399-8736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7602125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: