Provider Demographics
NPI:1871084509
Name:MCKENNA, JACLYN (MD)
Entity type:Individual
Prefix:DR
First Name:JACLYN
Middle Name:
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RHODE ISLAND HOSPITAL 593 EDDY STREET
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903
Mailing Address - Country:US
Mailing Address - Phone:401-444-4741
Mailing Address - Fax:401-444-4445
Practice Address - Street 1:1133 WESTCHESTER AVE
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10604-3516
Practice Address - Country:US
Practice Address - Phone:914-821-9296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-29
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILP04265207R00000X
NY322734207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine