Provider Demographics
NPI:1902007347
Name:MCKENZIE, JENNIFER IRENE (MSED, ATC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:IRENE
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:MSED, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1712 3RD ST
Mailing Address - Street 2:
Mailing Address - City:RADFORD
Mailing Address - State:VA
Mailing Address - Zip Code:24141-1228
Mailing Address - Country:US
Mailing Address - Phone:540-633-1712
Mailing Address - Fax:540-831-5082
Practice Address - Street 1:1712 3RD ST
Practice Address - Street 2:
Practice Address - City:RADFORD
Practice Address - State:VA
Practice Address - Zip Code:24141-1228
Practice Address - Country:US
Practice Address - Phone:540-633-1712
Practice Address - Fax:540-831-5082
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260006332255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer