=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275904419
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JILL KENNEDY PMHNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2015
-----------------------------------------------------
Last Update Date | 08/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16 PHILLIPS ST
-----------------------------------------------------
City | MASSENA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13662-2016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-764-8076
-----------------------------------------------------
Fax | 315-764-8079
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 608
-----------------------------------------------------
City | MALONE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12953-0608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-651-2302
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 541605
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 403653
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------