Provider Demographics
NPI:1487991428
Name:KENNEDY, JOSHUA DOUGLAS (P1 60159931)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:DOUGLAS
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:P1 60159931
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 CARRIAGE CT
Mailing Address - Street 2:
Mailing Address - City:KELSO
Mailing Address - State:WA
Mailing Address - Zip Code:98626-1891
Mailing Address - Country:US
Mailing Address - Phone:360-423-3582
Mailing Address - Fax:
Practice Address - Street 1:1500 3RD AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3229
Practice Address - Country:US
Practice Address - Phone:360-353-9046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-10
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP1 60159931225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant