Provider Demographics
NPI:1356352413
Name:MCKEAN, JACQUELYN R (MD)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:R
Last Name:MCKEAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 QUEEN ST
Mailing Address - Street 2:MEDICAL
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01610-2473
Mailing Address - Country:US
Mailing Address - Phone:508-860-7700
Mailing Address - Fax:508-860-7990
Practice Address - Street 1:81 RESERVOIR DR
Practice Address - Street 2:
Practice Address - City:ATHOL
Practice Address - State:MA
Practice Address - Zip Code:01331-4901
Practice Address - Country:US
Practice Address - Phone:978-248-5135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA206096207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0035749OtherNHP
MA1300709Medicaid
MA97679702OtherNETWORK HEALTH
MA042485308OtherNETWORK HEALTH-GROUP
MA49201OtherFALLON SELECT
MA0006767OtherNHP-GROUP
MAJ23197OtherBCBS
MAY10141OtherBCBS-GROUP
MA81738OtherCMSP
MA2437886OtherCIGNA
MAAA25557OtherHARVARD PILGRIM
MA97679702OtherNETWORK HEALTH
MA81738OtherCMSP
MA49201OtherFALLON SELECT
MAAA25557OtherHARVARD PILGRIM