Provider Demographics
NPI:1598151730
Name:MCKINNEY, JENNIFER A (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:MCKINNEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1077 GATEWAY LOOP
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-1114
Mailing Address - Country:US
Mailing Address - Phone:541-485-6478
Mailing Address - Fax:541-868-9606
Practice Address - Street 1:1077 GATEWAY LOOP
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-1114
Practice Address - Country:US
Practice Address - Phone:541-485-6478
Practice Address - Fax:541-868-9606
Is Sole Proprietor?:No
Enumeration Date:2015-04-14
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
ORPA180572363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR5007178902Medicaid
ORPA180572OtherMEDICAL LICENSE