MEDICARE: KIERNAN JUDD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor		FL

General Provider Information

NPI Number	:	1417806670
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIERNAN JUDD

Provider Business Mailing Address
First Line	:	340 MAGNOLIA CIR
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32403-5604
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	340 MAGNOLIA CIR
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32403-5612
Country	:	US
Telephone Number	:	850-481-9259
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/22/2026
Last Update Date	:	01/22/2026

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