Provider Demographics
NPI:1386087534
Name:KENISON, JEREMY ROWE (DO)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:ROWE
Last Name:KENISON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6095
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97708-6095
Mailing Address - Country:US
Mailing Address - Phone:541-706-5922
Mailing Address - Fax:541-706-6869
Practice Address - Street 1:630 N ARROWLEAF TRL
Practice Address - Street 2:
Practice Address - City:SISTERS
Practice Address - State:OR
Practice Address - Zip Code:97759-2610
Practice Address - Country:US
Practice Address - Phone:541-549-1318
Practice Address - Fax:541-588-6002
Is Sole Proprietor?:No
Enumeration Date:2013-04-08
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP 60502641207Q00000X
390200000X
ORDO214918207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program