Provider Demographics
NPI:1912409624
Name:MCKENZIE, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:MCKENZIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2725 ROUTE 75
Mailing Address - Street 2:
Mailing Address - City:KENOVA
Mailing Address - State:WV
Mailing Address - Zip Code:25530-9793
Mailing Address - Country:US
Mailing Address - Phone:304-638-9517
Mailing Address - Fax:
Practice Address - Street 1:1340 HAL GREER BLVD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701
Practice Address - Country:US
Practice Address - Phone:304-638-9517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-08
Last Update Date:2018-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAPRN79908CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered