Provider Demographics
NPI:1942558234
Name:JENNER, KIRSTEN MICHELLE
Entity Type:Individual
Prefix:MISS
First Name:KIRSTEN
Middle Name:MICHELLE
Last Name:JENNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6330 W THUNDERBIRD RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-4002
Mailing Address - Country:US
Mailing Address - Phone:602-329-0287
Mailing Address - Fax:
Practice Address - Street 1:6330 W THUNDERBIRD RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-4002
Practice Address - Country:US
Practice Address - Phone:623-487-5189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-17
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA78242355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant