Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101Y00000X | Counselor | CA |
NPI | 1003239807 |
---|---|
Provider Name | Mr. John Kennedy JR. |
First Address | Huntington Beach, CA 92648-1232 |
Second Address | Lynwood, CA 90262-3513 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/01/2014 |
Last Update Date | 04/04/2016 |