Provider Demographics
NPI:1073151510
Name:JONES, MACKENZIE RAE (LPC)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:RAE
Last Name:JONES
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W MONROE ST STE C7
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3997
Mailing Address - Country:US
Mailing Address - Phone:309-287-0610
Mailing Address - Fax:
Practice Address - Street 1:200 W MONROE ST STE C7
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3997
Practice Address - Country:US
Practice Address - Phone:309-287-0610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-16
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178015503101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional