MEDICARE: KENNRIDGE PSYCHOLOGICAL ASSOCIATES

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	103T00000X	Psychologist	1582	GA
2	106H00000X	Marriage & Family Therapist	818	GA
3	103TC0700X	Clinical Psychologist	3552	GA

General Provider Information

NPI Number	:	1780716258
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KENNRIDGE PSYCHOLOGICAL ASSOCIATES

Provider Business Mailing Address
First Line	:	6065 ROSWELL RD
Second Line	:	SUITE 725
City	:	SANDY SPRINGS
State	:	GA
Zip	:	30328-4043
Country	:	US
Telephone Number	:	770-956-9213
Fax Number	:	770-956-9218

Provider Business Practice Location Address
First Line	:	6065 ROSWELL ROAD
Second Line	:	SUITE 725
City	:	SANDY SPRINGS
State	:	GA
Zip	:	30328-4043
Country	:	US
Telephone Number	:	770-956-9213
Fax Number	:	770-956-9218

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CHARLES A. JENKINS
Credential	:	PSY.D
Telephone Number	:	770-956-9213

Provider Enumeration Date	:	03/11/2007
Last Update Date	:	05/14/2012

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