Provider Demographics
NPI:1841682929
Name:MCKEAN, JENNIFER (LAT, ATC PES)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MCKEAN
Suffix:
Gender:F
Credentials:LAT, ATC PES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1048 E COMMERCE BLVD
Mailing Address - Street 2:
Mailing Address - City:SLINGER
Mailing Address - State:WI
Mailing Address - Zip Code:53086-9326
Mailing Address - Country:US
Mailing Address - Phone:262-644-6268
Mailing Address - Fax:262-644-7860
Practice Address - Street 1:209 POLK ST
Practice Address - Street 2:
Practice Address - City:SLINGER
Practice Address - State:WI
Practice Address - Zip Code:53086-9234
Practice Address - Country:US
Practice Address - Phone:262-644-5261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-25
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1301-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer