Provider Demographics
NPI:1821468398
Name:KENNEDY, JANE (MT)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:JANE
Other - Middle Name:T
Other - Last Name:JAVELLANA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MT
Mailing Address - Street 1:11225 N 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-3757
Mailing Address - Country:US
Mailing Address - Phone:602-628-6636
Mailing Address - Fax:
Practice Address - Street 1:8601 N BLACK CANYON HWY STE 103
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-4155
Practice Address - Country:US
Practice Address - Phone:602-628-6636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-28
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-04684P225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist