MEDICARE: MISS JENICA LOREN MCKEOWN LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor
2	1041C0700X	Clinical Social Worker	62086	CA

General Provider Information

NPI Number	:	1801956156
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS JENICA LOREN MCKEOWN LCSW

Provider Business Mailing Address
First Line	:	2831 CAMINO DEL RIO S STE 203
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-3828
Country	:	US
Telephone Number	:	858-683-3793
Fax Number	:

Provider Business Practice Location Address
First Line	:	2831 CAMINO DEL RIO S STE 203
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-3828
Country	:	US
Telephone Number	:	858-683-3793
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/09/2006
Last Update Date	:	11/04/2021

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