Provider Demographics
NPI:1699030403
Name:MACKIE, JENNIFER A (MSED)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:MACKIE
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 LIBERTY AVE
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-4824
Mailing Address - Country:US
Mailing Address - Phone:631-225-1773
Mailing Address - Fax:
Practice Address - Street 1:44 LIBERTY AVE
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-4824
Practice Address - Country:US
Practice Address - Phone:631-225-1773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist