Provider Demographics
NPI:1801142104
Name:JUCKETT, MACKENZIE L (MS,APN)
Entity type:Individual
Prefix:MS
First Name:MACKENZIE
Middle Name:L
Last Name:JUCKETT
Suffix:
Gender:F
Credentials:MS,APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 EVES DRIVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053
Mailing Address - Country:US
Mailing Address - Phone:856-596-1600
Mailing Address - Fax:856-552-3218
Practice Address - Street 1:5 EVES DRIVE
Practice Address - Street 2:SUITE 300
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053
Practice Address - Country:US
Practice Address - Phone:856-596-1600
Practice Address - Fax:856-552-3218
Is Sole Proprietor?:No
Enumeration Date:2012-07-24
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00387900363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily