MEDICARE: ANNE EDITH KELLOGG LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	T0600	OR

General Provider Information

NPI Number	:	1033534219
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANNE EDITH KELLOGG LMFT

Provider Business Mailing Address
First Line	:	175 N OREGON ST
Second Line	:	#1004
City	:	JACKSONVILLE
State	:	OR
Zip	:	97530-9797
Country	:	US
Telephone Number	:	855-343-6012
Fax Number	:

Provider Business Practice Location Address
First Line	:	135 E E ST
Second Line	:
City	:	JACKSONVILLE
State	:	OR
Zip	:	97530-9246
Country	:	US
Telephone Number	:	855-343-6012
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/25/2014
Last Update Date	:	02/25/2014

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