Provider Demographics
NPI:1295511475
Name:MAZEKE, KENTISHA
Entity type:Individual
Prefix:
First Name:KENTISHA
Middle Name:
Last Name:MAZEKE
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 1:3908 VICTORIA LAKES DR S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32226-0709
Mailing Address - Country:US
Mailing Address - Phone:904-891-9390
Mailing Address - Fax:
Practice Address - Street 1:3908 VICTORIA LAKES DR S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32226-0709
Practice Address - Country:US
Practice Address - Phone:904-891-9390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-05
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA101108225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist