Provider Demographics
NPI:1861557829
Name:KENNEDY, JACK TIMOTHY (MA LICDC)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:TIMOTHY
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:MA LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8833 CHAPELSQUARE LN
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45249-4705
Mailing Address - Country:US
Mailing Address - Phone:513-774-9444
Mailing Address - Fax:513-774-9888
Practice Address - Street 1:8833 CHAPELSQUARE LN
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45249-4705
Practice Address - Country:US
Practice Address - Phone:513-774-9444
Practice Address - Fax:513-774-9888
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH991698101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)