Provider Demographics
NPI:1326296922
Name:MACKOWIAK, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MACKOWIAK
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 1:7 N ERIE ST
Mailing Address - Street 2:
Mailing Address - City:MAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14757-1090
Mailing Address - Country:US
Mailing Address - Phone:716-753-4104
Mailing Address - Fax:716-753-4230
Practice Address - Street 1:200 E 3RD ST
Practice Address - Street 2:5TH FLOOR MUNICIPAL BUILDING
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-5433
Practice Address - Country:US
Practice Address - Phone:716-661-8330
Practice Address - Fax:716-753-4230
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-08
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NYP75686101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program