Provider Demographics
NPI:1275082257
Name:KENYON, JOELLEN (MA LMHCA)
Entity Type:Individual
Prefix:MRS
First Name:JOELLEN
Middle Name:
Last Name:KENYON
Suffix:
Gender:F
Credentials:MA LMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 NW DOCK PL STE 4
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107-4846
Mailing Address - Country:US
Mailing Address - Phone:425-478-4276
Mailing Address - Fax:
Practice Address - Street 1:1900 NW DOCK PL STE 4
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-4846
Practice Address - Country:US
Practice Address - Phone:425-478-4276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-01
Last Update Date:2016-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC60588921172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker