Provider Demographics
NPI:1356718431
Name:KENNETTE, JON
Entity type:Individual
Prefix:
First Name:JON
Middle Name:
Last Name:KENNETTE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7425 MISSION VALLEY RD STE 201
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-4409
Mailing Address - Country:US
Mailing Address - Phone:619-291-3400
Mailing Address - Fax:
Practice Address - Street 1:7425 MISSION VALLEY RD STE 201
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4409
Practice Address - Country:US
Practice Address - Phone:619-291-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-25
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ1-0003391225100000X
CA305203225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE440195Y0XMedicare PIN