Basic Information
| Provider Information | |||||||||
| NPI: | 1548534894 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KENNEY | ||||||||
| FirstName: | KATIE | ||||||||
| MiddleName: | JAYNE BENTON | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1652 NW HUGHWOOD CT | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974718844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416733985 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1652 NW HUGHWOOD CT | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974718844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416733985 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2012 | ||||||||
| LastUpdateDate: | 04/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 04/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 1041C0700X | A5202 | OR | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 1041C0700X | L10568 | OR | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 500670891 | 05 | OR | MEDICAID |