Provider Demographics
NPI:1609812296
Name:MCKENNA, JEFFREY A (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:A
Last Name:MCKENNA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5110 E WARNER RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-3367
Mailing Address - Country:US
Mailing Address - Phone:480-753-1459
Mailing Address - Fax:480-753-5311
Practice Address - Street 1:5110 E WARNER RD
Practice Address - Street 2:SUITE 100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-3367
Practice Address - Country:US
Practice Address - Phone:480-753-1459
Practice Address - Fax:480-753-5311
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20965207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0866580OtherBC PROVIDER ID
AZ152538Medicaid
AZ152538Medicaid
AZF20293Medicare UPIN