Provider Demographics
NPI:1477879963
Name:MCKENZIE, JASON (CADC)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:MCKENZIE
Suffix:
Gender:M
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 726
Mailing Address - Street 2:
Mailing Address - City:LOUISA
Mailing Address - State:KY
Mailing Address - Zip Code:41230-0726
Mailing Address - Country:US
Mailing Address - Phone:859-762-0175
Mailing Address - Fax:
Practice Address - Street 1:105 BRANDON WAY
Practice Address - Street 2:SUITE A
Practice Address - City:MOUNT STERLING
Practice Address - State:KY
Practice Address - Zip Code:40353-8500
Practice Address - Country:US
Practice Address - Phone:859-762-0175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-09
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1296101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30610026Medicaid