Provider Demographics
NPI:1043924582
Name:KENNY, JESSICA SUZANNE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:SUZANNE
Last Name:KENNY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07727-1211
Mailing Address - Country:US
Mailing Address - Phone:732-546-5384
Mailing Address - Fax:
Practice Address - Street 1:689 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-2511
Practice Address - Country:US
Practice Address - Phone:732-431-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-10
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist