Provider Demographics
NPI:1740929470
Name:KENNERLY, JASMINE WHITNEY (LMT)
Entity type:Individual
Prefix:MISS
First Name:JASMINE
Middle Name:WHITNEY
Last Name:KENNERLY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:100 VILLAGE SQ APT 217
Mailing Address - Street 2:
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-2598
Mailing Address - Country:US
Mailing Address - Phone:631-624-4893
Mailing Address - Fax:
Practice Address - Street 1:100 VILLAGE SQ APT 217
Practice Address - Street 2:
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542-2598
Practice Address - Country:US
Practice Address - Phone:631-624-4893
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-01
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028678-1225700000X
028678-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist