Provider Demographics
NPI:1013210160
Name:MCKENZIE, JACLYN MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:JACLYN
Middle Name:MARIE
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5048 PINEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116-5132
Mailing Address - Country:US
Mailing Address - Phone:810-923-4826
Mailing Address - Fax:
Practice Address - Street 1:3601 WASHTENAW AVE
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-5277
Practice Address - Country:US
Practice Address - Phone:734-973-1712
Practice Address - Fax:734-973-1712
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-13
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004609152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist