Provider Demographics
NPI:1114268802
Name:KENNEY, JEREMY WILSON (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:WILSON
Last Name:KENNEY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2905 RIVER RD S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-9754
Mailing Address - Country:US
Mailing Address - Phone:971-258-7993
Mailing Address - Fax:
Practice Address - Street 1:2905 RIVER RD S
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-9754
Practice Address - Country:US
Practice Address - Phone:971-258-7993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-06
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2210103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical