Healthcare Provider Details

I. General information

NPI: 1154592517
Provider Name (Legal Business Name): JACKIE A MACKEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACKIE A MACKEY DUTTON

II. Dates (important events)

Enumeration Date: 03/13/2008
Last Update Date: 03/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

EXIT 102 OFF I - 40 1/2 MI SOUTH
SAN FIDEL NM
87049-0130
US

IV. Provider business mailing address

PO BOX 130
SAN FIDEL NM
87049-0130
US

V. Phone/Fax

Practice location:
  • Phone: 505-552-5385
  • Fax: 505-552-5473
Mailing address:
  • Phone: 505-551-5385
  • Fax: 505-552-5473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146M00000X
TaxonomyIntermediate Emergency Medical Technician
License Number03000684
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: