Provider Demographics
NPI:1447280094
Name:KENNEDY, NANCY A (PHD)
Entity type:Individual
Prefix:DR
First Name:NANCY
Middle Name:A
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:NANCY
Other - Middle Name:A
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:676 N SAINT CLAIR ST
Mailing Address - Street 2:SUITE 945
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2927
Mailing Address - Country:US
Mailing Address - Phone:312-695-7902
Mailing Address - Fax:312-695-6072
Practice Address - Street 1:676 N SAINT CLAIR ST
Practice Address - Street 2:SUITE 945
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2927
Practice Address - Country:US
Practice Address - Phone:312-695-7902
Practice Address - Fax:312-695-6072
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071005268103TC0700X
WI2003-57103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
322820Medicare UPIN