Provider Demographics
NPI:1316087646
Name:KENNY, JERRY M (DC)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:M
Last Name:KENNY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3418 SONOMA BLVD
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-2972
Mailing Address - Country:US
Mailing Address - Phone:707-552-2252
Mailing Address - Fax:707-552-2268
Practice Address - Street 1:3418 SONOMA BLVD
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-2972
Practice Address - Country:US
Practice Address - Phone:707-552-2252
Practice Address - Fax:707-552-2268
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC25578111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0255780Medicare UPIN