Provider Demographics
NPI:1013078377
Name:MACKENZIE, JEAN
Entity Type:Individual
Prefix:MS
First Name:JEAN
Middle Name:
Last Name:MACKENZIE
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 1:12 WIDGEON LN
Mailing Address - Street 2:
Mailing Address - City:WEST YARMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02673-3819
Mailing Address - Country:US
Mailing Address - Phone:508-398-6967
Mailing Address - Fax:
Practice Address - Street 1:27 PARK ST.
Practice Address - Street 2:CAPE COD HOSPITAL
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601
Practice Address - Country:US
Practice Address - Phone:508-771-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10206961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1020696OtherSOCIAL WORKER