Provider Demographics
NPI:1437539699
Name:KENYON, JAKE
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:KENYON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-1948
Mailing Address - Country:US
Mailing Address - Phone:774-319-3708
Mailing Address - Fax:
Practice Address - Street 1:455 BRAYTON AVE
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:MA
Practice Address - Zip Code:02726-2642
Practice Address - Country:US
Practice Address - Phone:508-679-2240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-03
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9833235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist