Provider Demographics
NPI:1306905104
Name:MACKENZIE, JESSIE JEAN (LMFT)
Entity type:Individual
Prefix:MRS
First Name:JESSIE
Middle Name:JEAN
Last Name:MACKENZIE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:941 CALLE MEJIA APT 202
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-1462
Mailing Address - Country:US
Mailing Address - Phone:505-728-0286
Mailing Address - Fax:
Practice Address - Street 1:360 FOG ROAD
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532
Practice Address - Country:US
Practice Address - Phone:505-692-6315
Practice Address - Fax:505-692-6341
Is Sole Proprietor?:No
Enumeration Date:2006-12-07
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0104321106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM57953767Medicaid