Provider Demographics
NPI:1558451468
Name:MACKENZIE, JACQUELINE IRENE (LMSW)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:IRENE
Last Name:MACKENZIE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:IRENE
Other - Last Name:WASHBURN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:28000 DEQUINDRE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-2468
Mailing Address - Country:US
Mailing Address - Phone:586-753-0405
Mailing Address - Fax:586-753-0404
Practice Address - Street 1:35455 GARFIELD RD STE C
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48035-2236
Practice Address - Country:US
Practice Address - Phone:586-792-5335
Practice Address - Fax:586-792-3061
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010633421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIQ26426165Medicare ID - Type Unspecified
MIS84105Medicare UPIN