Provider Demographics
NPI:1134678014
Name:JONES, MACKENZIE
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:JONES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:422 FOX ROAD
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:13030-9616
Mailing Address - Country:US
Mailing Address - Phone:315-546-5463
Mailing Address - Fax:
Practice Address - Street 1:159 W 1ST ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-2045
Practice Address - Country:US
Practice Address - Phone:315-342-9575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-03
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1050405161174400000X
NY1050406161174400000X
NY1037922161174400000X
NY1037908161174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist