1558345066 NPI number — JAMES M. KENNEDY JR. MD

Table of content: MS. RAYNA SIDNEY ARMAGH MFT-INTERN (NPI 1053422071)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558345066 NPI number — JAMES M. KENNEDY JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KENNEDY
Provider First Name:
JAMES
Provider Middle Name:
M.
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558345066
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/26/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 660599
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75266-0599
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25 NORTHRIDGE LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24450-3399
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-464-8700
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  L5008 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 161229305 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 161229307 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 161229310 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 161229302 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 161229308 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 161229312 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 161229311 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 161229303 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 161229304 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8U7228 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 161229301 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 161229309 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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