Provider Demographics
NPI:1235117508
Name:KENNEDY, JAN ELIZABETH (PHD)
Entity type:Individual
Prefix:DR
First Name:JAN
Middle Name:ELIZABETH
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
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Mailing Address - Street 1:15530 ELM PARK ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-2905
Mailing Address - Country:US
Mailing Address - Phone:210-396-9366
Mailing Address - Fax:
Practice Address - Street 1:3551 ROGER BROOKE DR
Practice Address - Street 2:
Practice Address - City:JBSA FT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:210-916-7014
Practice Address - Fax:210-916-3494
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX24866103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00367PMedicare ID - Type UnspecifiedPART B PROVIDER #