Provider Demographics
NPI:1558028027
Name:MACKEY, EBAN JAMES II
Entity Type:Individual
Prefix:
First Name:EBAN
Middle Name:JAMES
Last Name:MACKEY
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:544 EAST DR
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068-1363
Mailing Address - Country:US
Mailing Address - Phone:269-274-2963
Mailing Address - Fax:
Practice Address - Street 1:3475 BELLE CHASE WAY
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-4252
Practice Address - Country:US
Practice Address - Phone:517-882-3732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-19
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704280061363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health