Provider Demographics
NPI:1871470427
Name:KENNEDY, JOEL THOMAS
Entity type:Individual
Prefix:
First Name:JOEL
Middle Name:THOMAS
Last Name:KENNEDY
Suffix:
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 1:400 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DOUSMAN
Mailing Address - State:WI
Mailing Address - Zip Code:53118-9348
Mailing Address - Country:US
Mailing Address - Phone:262-470-8133
Mailing Address - Fax:
Practice Address - Street 1:400 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DOUSMAN
Practice Address - State:WI
Practice Address - Zip Code:53118-9348
Practice Address - Country:US
Practice Address - Phone:262-470-8133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-18
Last Update Date:2025-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4155-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant