Provider Demographics
NPI:1023640646
Name:STACK, MACKENZIE (PT)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:STACK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:
Other - Last Name:STEDDOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:3901 UNIVERSITY BLVD S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4312
Mailing Address - Country:US
Mailing Address - Phone:904-345-7251
Mailing Address - Fax:
Practice Address - Street 1:2121 S YUKON PKWY STE 200
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-7482
Practice Address - Country:US
Practice Address - Phone:405-578-5447
Practice Address - Fax:866-490-4693
Is Sole Proprietor?:No
Enumeration Date:2020-02-11
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist