Provider Demographics
NPI:1427532399
Name:MCKENZIE, JENNIFER LEA (MA CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LEA
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:BELMAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC-SLP
Mailing Address - Street 1:1532 PREHISTORIC HILL DR
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:MO
Mailing Address - Zip Code:63052-2288
Mailing Address - Country:US
Mailing Address - Phone:314-805-0477
Mailing Address - Fax:
Practice Address - Street 1:2840 SECKMAN RD
Practice Address - Street 2:
Practice Address - City:IMPERIAL
Practice Address - State:MO
Practice Address - Zip Code:63052-1941
Practice Address - Country:US
Practice Address - Phone:636-296-5707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011041709235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO235Z00000XMedicaid