Basic Information
Provider Information
NPI: 1205134632
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: KENNEDY
FirstName: JODI
MiddleName: MICHELE
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2330 ASTORIA BLVD
Address2:  
City: ASTORIA
State: NY
PostalCode: 111022941
CountryCode: US
TelephoneNumber: 7187791600
FaxNumber: 7188030895
Practice Location
Address1: 37-22 82ND ST.
Address2: CORONA ELMHURST GUIDANCE CENTER
City: JACKSON HEIGHTS
State: NY
PostalCode: 11732
CountryCode: US
TelephoneNumber: 7187791600
FaxNumber: 7188030895
Other Information
ProviderEnumerationDate: 03/09/2011
LastUpdateDate: 03/09/2011
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1041C0700X  Y Behavioral Health & Social Service ProvidersSocial WorkerClinical

No ID Information.


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