Healthcare Provider Details

I. General information

NPI: 1922380997
Provider Name (Legal Business Name): MR. JESSE PAUL KENT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2011
Last Update Date: 09/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 IL ROUTE 2
DIXON IL
61021-9118
US

IV. Provider business mailing address

203 GRANT AVE
DIXON IL
61021-2649
US

V. Phone/Fax

Practice location:
  • Phone: 815-284-6611
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: