Healthcare Provider Details

I. General information

NPI: 1770590242
Provider Name (Legal Business Name): DEBBIE JAY MACKIE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 OLIVE ST SUITE 500
SAINT LOUIS MO
63103-2303
US

IV. Provider business mailing address

1430 OLIVE ST SUITE 500
SAINT LOUIS MO
63103-2303
US

V. Phone/Fax

Practice location:
  • Phone: 314-206-3764
  • Fax: 314-206-3708
Mailing address:
  • Phone: 314-206-3764
  • Fax: 314-206-3708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number001385
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: