MEDICARE: LISA KAREN KENYON PT

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	225100000X	Physical Therapist	PT2979	AR
2	2251P0200X	Pediatric Physical Therapist	PT2979	AR

General Provider Information

NPI Number	:	1760682157
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA KAREN KENYON PT

Provider Business Mailing Address
First Line	:	3423 E HIGHLAND DR
Second Line	:	SUITE A
City	:	JONESBORO
State	:	AR
Zip	:	72401-6404
Country	:	US
Telephone Number	:	870-336-0021
Fax Number	:	870-336-0022

Provider Business Practice Location Address
First Line	:	3423 E HIGHLAND DR
Second Line	:	SUITE A
City	:	JONESBORO
State	:	AR
Zip	:	72401-6404
Country	:	US
Telephone Number	:	870-336-0021
Fax Number	:	870-336-0022

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

Provider Enumeration Date	:	07/23/2007
Last Update Date	:	07/23/2007

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