Provider Demographics
NPI:1124853379
Name:MCKENNA, JACKLYN PERILLO
Entity type:Individual
Prefix:
First Name:JACKLYN
Middle Name:PERILLO
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9601 161ST AVE
Mailing Address - Street 2:
Mailing Address - City:HOWARD BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11414-3828
Mailing Address - Country:US
Mailing Address - Phone:516-660-6307
Mailing Address - Fax:
Practice Address - Street 1:1400 OLD COUNTRY RD STE C103N
Practice Address - Street 2:
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-5156
Practice Address - Country:US
Practice Address - Phone:516-806-6363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-06
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1464094211174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist