Basic Information
Provider Information | |||||||||
NPI: | 1720545189 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KENNEDY | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | ATKINS | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1849 CHANNING WAY | ||||||||
Address2: |   | ||||||||
City: | BERKELEY | ||||||||
State: | CA | ||||||||
PostalCode: | 947031760 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5105490237 | ||||||||
FaxNumber: | 5105490237 | ||||||||
Practice Location | |||||||||
Address1: | 7200 BANCROFT AVE STE 267 | ||||||||
Address2: |   | ||||||||
City: | OAKLAND | ||||||||
State: | CA | ||||||||
PostalCode: | 946052403 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5107350864 | ||||||||
FaxNumber: | 5107461196 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/21/2019 | ||||||||
LastUpdateDate: | 02/21/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X |   |   | Y |   | Behavioral Health & Social Service Providers | Counselor |   |
No ID Information.