Provider Demographics
NPI:1225412208
Name:MCKENZIE, JENNA M (FNP)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:M
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 WATER STREET
Mailing Address - Street 2:2ND FLOOR CRED DEPT
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10041-0004
Mailing Address - Country:US
Mailing Address - Phone:646-680-2888
Mailing Address - Fax:516-542-5556
Practice Address - Street 1:640 HAWKINS AVE
Practice Address - Street 2:
Practice Address - City:LAKE RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-2324
Practice Address - Country:US
Practice Address - Phone:631-737-0100
Practice Address - Fax:631-471-1117
Is Sole Proprietor?:No
Enumeration Date:2015-07-19
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY661769163W00000X
NY340249363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00695941Medicaid
NY00695941Medicaid
WI331952Medicare Oscar/Certification
WIG100000410Medicare Oscar/Certification
WI331978Medicare Oscar/Certification
WI331058Medicare Oscar/Certification
WI331943Medicare Oscar/Certification
WI331945Medicare Oscar/Certification
WI331946Medicare Oscar/Certification
WI331944Medicare Oscar/Certification
WI331954Medicare Oscar/Certification
WI331009Medicare Oscar/Certification
WI331947Medicare Oscar/Certification
NYW6L111Medicare Oscar/Certification