Provider Demographics
NPI:1346328275
Name:MCKENNA, JENNIFER C (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:C
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3 GLEN COVE DR
Mailing Address - Street 2:STE 1
Mailing Address - City:ROCKPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04856-4232
Mailing Address - Country:US
Mailing Address - Phone:770-834-0170
Mailing Address - Fax:770-214-1546
Practice Address - Street 1:109 PROFESSIONAL PL
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3862
Practice Address - Country:US
Practice Address - Phone:770-834-0170
Practice Address - Fax:770-214-1546
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD18326207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA002047OtherBLUE CROSS BLUE SHIELD
GA000797288CMedicaid
GA332133OtherWELLCARE
GA581456616OtherTAX ID
GA000797288COtherPEACH STATE
GAG95059Medicare UPIN
GA000797288CMedicaid