Basic Information
| Provider Information | |||||||||
| NPI: | 1639845449 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KINKEY | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975012756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417721777 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3397 DELTA WATERS RD | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975045852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417724648 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2021 | ||||||||
| LastUpdateDate: | 09/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247000000X | N | Technologists, Technicians & Other Technical Service Providers | Technician, Health Information | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.