Healthcare Provider Details

I. General information

NPI: 1568949006
Provider Name (Legal Business Name): MCKENNA TAYLOR ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MCKENNA JENKINS

II. Dates (important events)

Enumeration Date: 07/27/2018
Last Update Date: 07/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 SFH BRIGHAM YOUNG UNIVERSITY
PROVO UT
84602
US

IV. Provider business mailing address

2693 W 1210 N
PROVO UT
84601-5024
US

V. Phone/Fax

Practice location:
  • Phone: 801-422-2946
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000032144
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: