Provider Demographics
NPI:1548017908
Name:KENNEDY, WREN ELLIOT JANE
Entity type:Individual
Prefix:
First Name:WREN
Middle Name:ELLIOT JANE
Last Name:KENNEDY
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 E ELLENDALE AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:OR
Mailing Address - Zip Code:97338-9353
Mailing Address - Country:US
Mailing Address - Phone:503-623-5588
Mailing Address - Fax:
Practice Address - Street 1:2200 E ELLENDALE AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-9353
Practice Address - Country:US
Practice Address - Phone:503-623-5588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-03
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ORA154871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health