Provider Demographics
NPI:1235480880
Name:MCKENZIE, JESICA DENISE (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:JESICA
Middle Name:DENISE
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 NORTH STATE STREET
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5452
Mailing Address - Fax:601-815-3322
Practice Address - Street 1:2500 NORTH STATE STREET
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5452
Practice Address - Fax:601-815-3322
Is Sole Proprietor?:No
Enumeration Date:2012-09-23
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR872871163W00000X
UT8434518-4405363LF0000X
FL9416834363LF0000X
MS810649363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03638074Medicaid
MS505389YJ5DMedicare PIN
MSP01753959Medicare PIN