Provider Demographics
NPI:1437452000
Name:KENYON, JACQUELINE KAY (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:KAY
Last Name:KENYON
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:MISS
Other - First Name:JACQUELINE
Other - Middle Name:KAY
Other - Last Name:BURDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:3555 EAST FRY BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635
Mailing Address - Country:US
Mailing Address - Phone:520-515-2790
Mailing Address - Fax:
Practice Address - Street 1:3555 E FRY BLVD
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2972
Practice Address - Country:US
Practice Address - Phone:520-515-2790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-21
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6951235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ#SLP6951Medicaid