Provider Demographics
NPI:1902374853
Name:MCKENNA, JANE CLAIR
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:CLAIR
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 1:3975 FAIR RIDGE DR # 125
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2911
Mailing Address - Country:US
Mailing Address - Phone:032-598-4237
Mailing Address - Fax:
Practice Address - Street 1:3975 FAIR RIDGE DR # 125
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-2911
Practice Address - Country:US
Practice Address - Phone:703-259-8423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-08
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP139613363LA2100X
VA0024187051363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX397549201Medicaid