Provider Demographics
NPI:1518571652
Name:MCKENNA, MCKENNA JANE (MOT)
Entity Type:Individual
Prefix:
First Name:MCKENNA
Middle Name:JANE
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:453 HIGHLAND PL
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92027-3710
Mailing Address - Country:US
Mailing Address - Phone:760-504-6696
Mailing Address - Fax:
Practice Address - Street 1:453 HIGHLAND PL
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92027-3710
Practice Address - Country:US
Practice Address - Phone:760-504-6696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-05
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21092225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist