Provider Demographics
NPI:1467210765
Name:WESENBERG, KENNEDY JEAN (LMT)
Entity Type:Individual
Prefix:
First Name:KENNEDY
Middle Name:JEAN
Last Name:WESENBERG
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:KENNEDY
Other - Middle Name:JEAN
Other - Last Name:HANSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:4529 RIDGEWEST DR E
Mailing Address - Street 2:
Mailing Address - City:LAKE TAPPS
Mailing Address - State:WA
Mailing Address - Zip Code:98391-9183
Mailing Address - Country:US
Mailing Address - Phone:253-691-6752
Mailing Address - Fax:
Practice Address - Street 1:21707 103RD AVENUE CT E STE B201
Practice Address - Street 2:
Practice Address - City:GRAHAM
Practice Address - State:WA
Practice Address - Zip Code:98338-8308
Practice Address - Country:US
Practice Address - Phone:253-847-7517
Practice Address - Fax:253-847-7467
Is Sole Proprietor?:No
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61512646225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist