Provider Demographics
NPI:1063061471
Name:KENYON, JILL R (MSPT)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:R
Last Name:KENYON
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 PROGRESS DR
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-2450
Mailing Address - Country:US
Mailing Address - Phone:860-529-4260
Mailing Address - Fax:860-257-8500
Practice Address - Street 1:123 PROGRESS DR
Practice Address - Street 2:
Practice Address - City:WETHERSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06109-2450
Practice Address - Country:US
Practice Address - Phone:860-529-4260
Practice Address - Fax:860-257-8500
Is Sole Proprietor?:No
Enumeration Date:2019-09-09
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT007194225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist