Provider Demographics
NPI:1396713780
Name:MCKENNA, JEFFREY K (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:K
Last Name:MCKENNA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3024 E EMPIRE ST
Mailing Address - Street 2:SECOND FLOOR STE E & F
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-5402
Mailing Address - Country:US
Mailing Address - Phone:309-451-3376
Mailing Address - Fax:309-452-3376
Practice Address - Street 1:100 DEERPATH
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:IL
Practice Address - Zip Code:61920-9427
Practice Address - Country:US
Practice Address - Phone:217-234-8000
Practice Address - Fax:217-234-8003
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-118958207N00000X, 207NS0135X
IL036.118958207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology