Healthcare Provider Details

I. General information

NPI: 1194469635
Provider Name (Legal Business Name): JENNIE RAE MCKINNEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2022
Last Update Date: 04/21/2022
Certification Date: 04/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 HAL GREER BLVD
HUNTINGTON WV
25701-3804
US

IV. Provider business mailing address

1340 HAL GREER BLVD
HUNTINGTON WV
25701-3804
US

V. Phone/Fax

Practice location:
  • Phone: 304-526-2075
  • Fax: 304-526-2006
Mailing address:
  • Phone: 304-526-2075
  • Fax: 304-526-2006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number89310
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: