Provider Demographics
NPI:1922384213
Name:MACKIE, JENNIFER GAYLE
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:GAYLE
Last Name:MACKIE
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 1:9132 WEEPING HOLLOW AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89178-6231
Mailing Address - Country:US
Mailing Address - Phone:702-513-9005
Mailing Address - Fax:
Practice Address - Street 1:9132 WEEPING HOLLOW AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89178-6231
Practice Address - Country:US
Practice Address - Phone:702-513-9005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-31
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor