Provider Demographics
NPI:1720131717
Name:JANER, KEVIN WILLIAM (PHD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:WILLIAM
Last Name:JANER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 SW 12TH AVE STE 224
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2083
Mailing Address - Country:US
Mailing Address - Phone:971-251-9856
Mailing Address - Fax:503-206-6713
Practice Address - Street 1:1201 SW 12TH AVE STE 224
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2083
Practice Address - Country:US
Practice Address - Phone:971-251-9856
Practice Address - Fax:503-206-6713
Is Sole Proprietor?:No
Enumeration Date:2007-01-21
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2976103G00000X, 103TC0700X
OR3191103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP09934Medicare UPIN
NYVD0222Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER