MEDICARE: MRS. JOELLEN KENYON MA LMHCA

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	172V00000X	Community Health Worker	MC60588921	WA

General Provider Information

NPI Number	:	1275082257
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JOELLEN KENYON MA LMHCA

Provider Business Mailing Address
First Line	:	1900 NW DOCK PL STE 4
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98107-4846
Country	:	US
Telephone Number	:	425-478-4276
Fax Number	:

Provider Business Practice Location Address
First Line	:	1900 NW DOCK PL STE 4
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98107-4846
Country	:	US
Telephone Number	:	425-478-4276
Fax Number	:

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

Provider Enumeration Date	:	10/01/2016
Last Update Date	:	10/01/2016

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