Provider Demographics
NPI:1003431271
Name:KENYON, JESSICA A (OTR/L)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:A
Last Name:KENYON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:A
Other - Last Name:WELSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15870 N HAGGERTY RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-4872
Mailing Address - Country:US
Mailing Address - Phone:734-420-7917
Mailing Address - Fax:
Practice Address - Street 1:15870 N HAGGERTY RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-4872
Practice Address - Country:US
Practice Address - Phone:734-420-7917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-12
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201010793225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist