Provider Demographics
NPI:1982377073
Name:PENNER, KEVIN JON (CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:JON
Last Name:PENNER
Suffix:
Gender:M
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6270 N GOVERNMENT WAY
Mailing Address - Street 2:
Mailing Address - City:DALTON GARDENS
Mailing Address - State:ID
Mailing Address - Zip Code:83815-9214
Mailing Address - Country:US
Mailing Address - Phone:208-666-0611
Mailing Address - Fax:208-664-0566
Practice Address - Street 1:6270 N GOVERNMENT WAY
Practice Address - Street 2:
Practice Address - City:DALTON GARDENS
Practice Address - State:ID
Practice Address - Zip Code:83815-9214
Practice Address - Country:US
Practice Address - Phone:208-666-0611
Practice Address - Fax:208-664-0566
Is Sole Proprietor?:No
Enumeration Date:2021-07-26
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-4868235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist