Provider Demographics
NPI:1902533078
Name:ICKES, KENDRA W
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:W
Last Name:ICKES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KENDRA
Other - Middle Name:
Other - Last Name:WOMACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16083 SW UPPER BOONES FERRY RD STE 300
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7736
Mailing Address - Country:US
Mailing Address - Phone:503-443-6156
Mailing Address - Fax:
Practice Address - Street 1:1520 W STATE ST STE 210
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4026
Practice Address - Country:US
Practice Address - Phone:208-336-8433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-08
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist