Provider Demographics
NPI:1497632244
Name:KINNEY, DERRICK JON
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:JON
Last Name:KINNEY
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 1:7763 S BIRCH RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BRITT
Mailing Address - State:MN
Mailing Address - Zip Code:55710-8272
Mailing Address - Country:US
Mailing Address - Phone:218-750-9308
Mailing Address - Fax:
Practice Address - Street 1:7763 S BIRCH RIDGE RD
Practice Address - Street 2:
Practice Address - City:BRITT
Practice Address - State:MN
Practice Address - Zip Code:55710-8272
Practice Address - Country:US
Practice Address - Phone:218-750-9308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-20
Last Update Date:2025-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNIR814158171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications