Basic Information
| Provider Information | |||||||||
| NPI: | 1659385482 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VAN KESSEL | ||||||||
| FirstName: | JEANETTE | ||||||||
| MiddleName: | |||||||||
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| Credential: | CCC-A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 NE FRANKLIN AVE | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977014917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413896669 | ||||||||
| FaxNumber: | 5413898865 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 NE FRANKLIN AVE | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977014917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413896669 | ||||||||
| FaxNumber: | 5413898865 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 11/28/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 20957 | OR | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 038195 | 05 | OR | MEDICAID |