Provider Demographics
NPI:1215247036
Name:MCKENNA, JODY S (PT)
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:S
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 FOUNTAIN ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-3848
Mailing Address - Country:US
Mailing Address - Phone:207-852-8390
Mailing Address - Fax:
Practice Address - Street 1:117 BENNOCH RD
Practice Address - Street 2:
Practice Address - City:ORONO
Practice Address - State:ME
Practice Address - Zip Code:04473-3620
Practice Address - Country:US
Practice Address - Phone:207-866-4914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-14
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT1326225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist