Provider Demographics
NPI:1619157443
Name:KENNEDY, JENNIFER MARJORIE (RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MARJORIE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4805 NE GLISAN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-2933
Mailing Address - Country:US
Mailing Address - Phone:503-216-8125
Mailing Address - Fax:503-215-6576
Practice Address - Street 1:4805 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2933
Practice Address - Country:US
Practice Address - Phone:503-216-8125
Practice Address - Fax:503-215-6576
Is Sole Proprietor?:No
Enumeration Date:2007-11-08
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR511133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered