Basic Information
| Provider Information | |||||||||
| NPI: | 1356352413 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCKEAN | ||||||||
| FirstName: | JACQUELYN | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 26 QUEEN ST | ||||||||
| Address2: | MEDICAL | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016102473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088607700 | ||||||||
| FaxNumber: | 5088607990 | ||||||||
| Practice Location | |||||||||
| Address1: | 81 RESERVOIR DR | ||||||||
| Address2: | |||||||||
| City: | ATHOL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 013314901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9782485135 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 01/30/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 206096 | MA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0035749 | 01 | MA | NHP | OTHER | 1300709 | 05 | MA | MEDICAID | 97679702 | 01 | MA | NETWORK HEALTH | OTHER | 042485308 | 01 | MA | NETWORK HEALTH-GROUP | OTHER | 49201 | 01 | MA | FALLON SELECT | OTHER | 0006767 | 01 | MA | NHP-GROUP | OTHER | J23197 | 01 | MA | BCBS | OTHER | Y10141 | 01 | MA | BCBS-GROUP | OTHER | 81738 | 01 | MA | CMSP | OTHER | 2437886 | 01 | MA | CIGNA | OTHER | AA25557 | 01 | MA | HARVARD PILGRIM | OTHER |