Healthcare Provider Details

I. General information

NPI: 1851736607
Provider Name (Legal Business Name): JENNIFER K MACKEY LMSW, LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2013
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 S HILLSIDE ST
WICHITA KS
67211-3002
US

IV. Provider business mailing address

714 S HILLSIDE
WICHITA KS
67211-3602
US

V. Phone/Fax

Practice location:
  • Phone: 316-295-4800
  • Fax: 316-295-4811
Mailing address:
  • Phone: 316-295-4800
  • Fax: 316-295-4811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number665
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number10534
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: