Healthcare Provider Details

I. General information

NPI: 1164029864
Provider Name (Legal Business Name): MACKENZIE JO LEMON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2020
Last Update Date: 10/06/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1319 CALLE AVANZADO
SAN CLEMENTE CA
92673-6351
US

IV. Provider business mailing address

400 S VAN BUREN ST
STOUGHTON WI
53589-2311
US

V. Phone/Fax

Practice location:
  • Phone: 949-272-6146
  • Fax:
Mailing address:
  • Phone: 262-993-6750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-25-84106
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number16501
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: