Provider Demographics
NPI:1881820553
Name:KENNEL, MARY JANE (LMT)
Entity type:Individual
Prefix:
First Name:MARY JANE
Middle Name:
Last Name:KENNEL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:990 NW CIRCLE BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-1410
Mailing Address - Country:US
Mailing Address - Phone:541-768-6412
Mailing Address - Fax:
Practice Address - Street 1:990 NW CIRCLE BLVD STE 201
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-1410
Practice Address - Country:US
Practice Address - Phone:541-768-6412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-08
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5919174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR5919OtherOREGON STATE LICENSE