Provider Demographics
NPI:1154592517
Name:MACKEY, JACKIE A
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:A
Last Name:MACKEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:A
Other - Last Name:MACKEY DUTTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:SAN FIDEL
Mailing Address - State:NM
Mailing Address - Zip Code:87049-0130
Mailing Address - Country:US
Mailing Address - Phone:505-551-5385
Mailing Address - Fax:505-552-5473
Practice Address - Street 1:EXIT 102 OFF I - 40 1/2 MI SOUTH
Practice Address - Street 2:
Practice Address - City:SAN FIDEL
Practice Address - State:NM
Practice Address - Zip Code:87049-0130
Practice Address - Country:US
Practice Address - Phone:505-552-5385
Practice Address - Fax:505-552-5473
Is Sole Proprietor?:No
Enumeration Date:2008-03-13
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM03000684146M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146M00000XEmergency Medical Service ProvidersEmergency Medical Technician, Intermediate