Provider Demographics
NPI:1215550827
Name:MCKEON, JENNIFER MICHELE (PHD, ATC, CSCS)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:MICHELE
Last Name:MCKEON
Suffix:
Gender:F
Credentials:PHD, ATC, CSCS
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MICHELE
Other - Last Name:MEDINA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, ATC, CSCS
Mailing Address - Street 1:953 DANBY ROAD
Mailing Address - Street 2:HILL CENTER, ROOM G65
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-7002
Mailing Address - Country:US
Mailing Address - Phone:607-274-1456
Mailing Address - Fax:
Practice Address - Street 1:953 DANBY ROAD
Practice Address - Street 2:HILL CENTER, ROOM G65
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-7002
Practice Address - Country:US
Practice Address - Phone:607-274-1456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-19
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0026672255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer