Provider Demographics
NPI:1871248955
Name:JARDELL, MACKENZIE
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:JARDELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1131 N UTAH ST
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22201-5730
Mailing Address - Country:US
Mailing Address - Phone:409-719-3456
Mailing Address - Fax:
Practice Address - Street 1:7150 HERITAGE VILLAGE PLZ STE 201
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-3064
Practice Address - Country:US
Practice Address - Phone:571-318-9141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-16
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704014593101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health