=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720323819
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KENNEDY HERRMANN & ASSOCIATES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2012
-----------------------------------------------------
Last Update Date | 11/14/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7863 BROADWAY STE 236
-----------------------------------------------------
City | MERRILLVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46410-5554
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-769-2141
-----------------------------------------------------
Fax | 219-769-2675
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 10126
-----------------------------------------------------
City | MERRILLVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46411-0126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-769-2141
-----------------------------------------------------
Fax | 219-769-2675
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. JESSICA L KENNEDY HERRMANN
-----------------------------------------------------
Credential | LCSW, LCAC
-----------------------------------------------------
Telephone | 219-393-9033
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 34006146A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------