Provider Demographics
NPI:1538617634
Name:SHARP, KENNETH JASON II
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:JASON
Last Name:SHARP
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14799 DIX TOLEDO RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-2507
Mailing Address - Country:US
Mailing Address - Phone:313-831-5535
Mailing Address - Fax:313-831-2608
Practice Address - Street 1:14799 DIX TOLEDO RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2507
Practice Address - Country:US
Practice Address - Phone:313-831-5535
Practice Address - Fax:313-831-2608
Is Sole Proprietor?:No
Enumeration Date:2016-09-17
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIS610465373288106S00000X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician