Provider Demographics
NPI:1659385482
Name:VAN KESSEL, JEANETTE (CCC-A)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:
Last Name:VAN KESSEL
Suffix:
Gender:F
Credentials:CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 NE FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-4917
Mailing Address - Country:US
Mailing Address - Phone:541-389-6669
Mailing Address - Fax:541-389-8865
Practice Address - Street 1:301 NE FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4917
Practice Address - Country:US
Practice Address - Phone:541-389-6669
Practice Address - Fax:541-389-8865
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20957231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR038195Medicaid
OR038195Medicaid