Provider Demographics
NPI:1922237759
Name:MCKENNA, JESSICA J (OTR/L)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:J
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:J
Other - Last Name:CULLINAN, GALILEI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:500 GRANITE AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:MA
Mailing Address - Zip Code:02186-5626
Mailing Address - Country:US
Mailing Address - Phone:617-691-7140
Mailing Address - Fax:304-292-0174
Practice Address - Street 1:500 GRANITE AVE STE 1
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:MA
Practice Address - Zip Code:02186-5626
Practice Address - Country:US
Practice Address - Phone:617-691-7140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-14
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC01116225X00000X
WV1435225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810015720Medicaid