1215550827 NPI number — DR. JENNIFER MICHELE MCKEON PHD, ATC, CSCS

Table of content: DR. JENNIFER MICHELE MCKEON PHD, ATC, CSCS (NPI 1215550827)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215550827 NPI number — DR. JENNIFER MICHELE MCKEON PHD, ATC, CSCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCKEON
Provider First Name:
JENNIFER
Provider Middle Name:
MICHELE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD, ATC, CSCS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MEDINA
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
MICHELE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS, ATC, CSCS
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1215550827
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/19/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
953 DANBY ROAD
Provider Second Line Business Mailing Address:
HILL CENTER, ROOM G65
Provider Business Mailing Address City Name:
ITHACA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14850-7002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
607-274-1456
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
953 DANBY ROAD
Provider Second Line Business Practice Location Address:
HILL CENTER, ROOM G65
Provider Business Practice Location Address City Name:
ITHACA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14850-7002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-274-1456
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/19/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , with the licence number:  002667 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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