Healthcare Provider Details

I. General information

NPI: 1003697491
Provider Name (Legal Business Name): JENNIFER REBECCA MCKEE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2023
Last Update Date: 11/20/2023
Certification Date: 10/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4125 ALPHA ST
SAN DIEGO CA
92113-4553
US

IV. Provider business mailing address

8910 CLAIREMONT MESA BLVD
SAN DIEGO CA
92123-1104
US

V. Phone/Fax

Practice location:
  • Phone: 619-952-4124
  • Fax:
Mailing address:
  • Phone: 619-952-4124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number15856
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number15856
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: