Provider Demographics
NPI:1851797567
Name:MACKIEWICZ, JEANINE (PA-C, MMS)
Entity Type:Individual
Prefix:MS
First Name:JEANINE
Middle Name:
Last Name:MACKIEWICZ
Suffix:
Gender:F
Credentials:PA-C, MMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 FOREST GLEN RD
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-1460
Mailing Address - Country:US
Mailing Address - Phone:301-754-7230
Mailing Address - Fax:301-754-7228
Practice Address - Street 1:1500 FOREST GLEN RD
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-1460
Practice Address - Country:US
Practice Address - Phone:301-754-7230
Practice Address - Fax:301-754-7228
Is Sole Proprietor?:No
Enumeration Date:2014-11-06
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0005595363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical