Healthcare Provider Details

I. General information

NPI: 1811804545
Provider Name (Legal Business Name): MCKENZIE JADE CROFFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2240 COUNTY ROAD 1270
WILLOW SPRINGS MO
65793-3393
US

IV. Provider business mailing address

2423 COVINGTON MDWS
POPLAR BLUFF MO
63901-2415
US

V. Phone/Fax

Practice location:
  • Phone: 573-883-6761
  • Fax:
Mailing address:
  • Phone: 573-707-0071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2026011462
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: