Healthcare Provider Details

I. General information

NPI: 1144994666
Provider Name (Legal Business Name): VAN KENNEDY MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2021
Last Update Date: 12/05/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 E BROADWAY STE 303
EUGENE OR
97401-3154
US

IV. Provider business mailing address

132 E BROADWAY STE 303
EUGENE OR
97401-3154
US

V. Phone/Fax

Practice location:
  • Phone: 541-525-4460
  • Fax:
Mailing address:
  • Phone: 541-525-4460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC7713
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: