Healthcare Provider Details

I. General information

NPI: 1467361881
Provider Name (Legal Business Name): MACKENZIE JAENICKE
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1390 MARKET ST STE 200
SAN FRANCISCO CA
94102-5404
US

IV. Provider business mailing address

1390 MARKET ST STE 200
SAN FRANCISCO CA
94102-5404
US

V. Phone/Fax

Practice location:
  • Phone: 877-627-0369
  • Fax:
Mailing address:
  • Phone: 877-627-0369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN273519
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: