Healthcare Provider Details

I. General information

NPI: 1720131717
Provider Name (Legal Business Name): KEVIN WILLIAM JANER PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2007
Last Update Date: 11/15/2023
Certification Date: 11/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 SW 12TH AVE STE 224
PORTLAND OR
97205-2083
US

IV. Provider business mailing address

1201 SW 12TH AVE STE 224
PORTLAND OR
97205-2083
US

V. Phone/Fax

Practice location:
  • Phone: 971-251-9856
  • Fax: 503-206-6713
Mailing address:
  • Phone: 971-251-9856
  • Fax: 503-206-6713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number2976
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number3191
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2976
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3191
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: