Provider Demographics
NPI:1124105572
Name:MCKINNEY, JAKE STEWART (PHD)
Entity type:Individual
Prefix:DR
First Name:JAKE
Middle Name:STEWART
Last Name:MCKINNEY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 KEOWEE TRL
Mailing Address - Street 2:
Mailing Address - City:CLEMSON
Mailing Address - State:SC
Mailing Address - Zip Code:29631-1448
Mailing Address - Country:US
Mailing Address - Phone:864-654-9263
Mailing Address - Fax:
Practice Address - Street 1:214 KEOWEE TRL
Practice Address - Street 2:
Practice Address - City:CLEMSON
Practice Address - State:SC
Practice Address - Zip Code:29631-1448
Practice Address - Country:US
Practice Address - Phone:864-654-9263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC91101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor