Provider Demographics
NPI:1942387675
Name:MACKENZIE, JESSICA ELIZABETH (DC)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:ELIZABETH
Last Name:MACKENZIE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 ANGELA DR
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-1779
Mailing Address - Country:US
Mailing Address - Phone:203-265-4945
Mailing Address - Fax:860-223-0468
Practice Address - Street 1:25 COURT ST
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06051-2211
Practice Address - Country:US
Practice Address - Phone:860-229-1490
Practice Address - Fax:860-223-0468
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1362111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTU84115Medicare UPIN