Basic Information
| Provider Information | |||||||||
| NPI: | 1346328275 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCKENNA | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3 GLEN COVE DR | ||||||||
| Address2: | STE 1 | ||||||||
| City: | ROCKPORT | ||||||||
| State: | ME | ||||||||
| PostalCode: | 048564232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708340170 | ||||||||
| FaxNumber: | 7702141546 | ||||||||
| Practice Location | |||||||||
| Address1: | 109 PROFESSIONAL PL | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301173862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708340170 | ||||||||
| FaxNumber: | 7702141546 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 02/17/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | MD18326 | ME | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 002047 | 01 | GA | BLUE CROSS BLUE SHIELD | OTHER | 000797288C | 05 | GA | MEDICAID | 332133 | 01 | GA | WELLCARE | OTHER | 581456616 | 01 | GA | TAX ID | OTHER | 000797288C | 01 | GA | PEACH STATE | OTHER |