Provider Demographics
NPI:1679081574
Name:MACKEY, JENNIFER ANN (APRN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:MACKEY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3170 KETTERING BLVD
Mailing Address - Street 2:BUILDING B, 3RD FLOOR
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:937-991-3186
Mailing Address - Fax:937-223-9811
Practice Address - Street 1:1130 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45322-2819
Practice Address - Country:US
Practice Address - Phone:937-208-6879
Practice Address - Fax:937-208-6886
Is Sole Proprietor?:No
Enumeration Date:2018-01-14
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.021227363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0008863Medicaid