Basic Information
Provider Information
NPI: 1003139635
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MCINTOSH-JONES
FirstName: KENYETTA
MiddleName: D.
NamePrefix: MRS.
NameSuffix:  
Credential: LCSW
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2736 GREENMILL DR
Address2:  
City: MEMPHIS
State: TN
PostalCode: 381198304
CountryCode: US
TelephoneNumber: 9013750918
FaxNumber:  
Practice Location
Address1: 1030 JEFFERSON AVE
Address2:  
City: MEMPHIS
State: TN
PostalCode: 381042127
CountryCode: US
TelephoneNumber: 9015238990
FaxNumber:  
Other Information
ProviderEnumerationDate: 03/10/2010
LastUpdateDate: 03/10/2010
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1041C0700X149013440ILN Behavioral Health & Social Service ProvidersSocial WorkerClinical
1041C0700X2446-CARN Behavioral Health & Social Service ProvidersSocial WorkerClinical
1041C0700X5147TNY Behavioral Health & Social Service ProvidersSocial WorkerClinical

No ID Information.


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