Kenneth Michael Pettis Jr., LMFT

Primary specialty

Marriage & Family TherapistTaxonomy code 106H00000X

License

150072 Issued in CA

Practice address

315 W Pine St #3, 95240
Lodi, CA 95240-4094

Phone

(209) 366-2273

NPI assigned

Dec 1, 2022

Last updated

Oct 15, 2024By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in CA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• An Elegant Sufficiency, a Psychological Corporation

  • Clinical Psychologist
  • Stockton, CA
  • NPI 1427655810
  Medicare reassignment NPD
• Holt Counseling Center

  • Community/Behavioral Health Agency
  • Lodi, CA
  • NPI 1548663362
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1669852800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1728950400000",
    "number": "1699485540",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5250 CLAREMONT AVE STE 118",
            "city": "STOCKTON",
            "state": "CA",
            "postal_code": "952075700",
            "telephone_number": "719-200-2238"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "315 W PINE ST #3, 95240",
            "city": "LODI",
            "state": "CA",
            "postal_code": "952404094",
            "telephone_number": "209-366-2273"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETTIS",
        "first_name": "KENNETH",
        "middle_name": "MICHAEL",
        "name_prefix": "Mr.",
        "name_suffix": "Jr.",
        "credential": "LMFT",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2022-12-01",
        "last_updated": "2024-10-15",
        "certification_date": "2024-10-15",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "106H00000X",
            "taxonomy_group": "",
            "desc": "Marriage & Family Therapist",
            "state": "CA",
            "license": "150072",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Nathen Andrew Perkins, M.D.
• Kathryn Perry
• Peter V. Hetzner, O.D. (Lodi Optometry Group)
• Sheena Peters
• Sara Marie Peterson, SLP
• Victor Anhkhoa Pham, PHARMD
• Minh Duc Phan
• Yvonne Phan
• Sunny Koipurathu Philip Jr., M.D.
• Genevieve Philiponis, MD

• Marriage & Family Therapist in Lodi, CA
• Providers in Lodi, CA by specialty
• Marriage & Family Therapist in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 15, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.