Provider Demographics
NPI:1306998141
Name:ZIMMERMAN, KENNETH E (PMHNP)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:E
Last Name:ZIMMERMAN
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 CLUB RD STE 360
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-2463
Mailing Address - Country:US
Mailing Address - Phone:541-912-1295
Mailing Address - Fax:541-972-8779
Practice Address - Street 1:66 CLUB RD STE 360
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2463
Practice Address - Country:US
Practice Address - Phone:541-912-1295
Practice Address - Fax:541-972-8779
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR08004600RN363LP0808X
OR008004600N6363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500753024Medicaid