Provider Demographics
NPI:1083616734
Name:MCKENNEY, JANICE MARIE (MD)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:MARIE
Last Name:MCKENNEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 4TH ST SE
Mailing Address - Street 2:
Mailing Address - City:HURON
Mailing Address - State:SD
Mailing Address - Zip Code:57350-2509
Mailing Address - Country:US
Mailing Address - Phone:605-352-8691
Mailing Address - Fax:605-352-8704
Practice Address - Street 1:111 4TH ST SE
Practice Address - Street 2:
Practice Address - City:HURON
Practice Address - State:SD
Practice Address - Zip Code:57350-2509
Practice Address - Country:US
Practice Address - Phone:605-352-8691
Practice Address - Fax:605-352-8704
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD3733207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A016OtherTRICARE
SD0002386OtherWELLMAK BCBS
SD5600270Medicaid
SDS3335Medicare PIN
SD0002386OtherWELLMAK BCBS
A016OtherTRICARE