Healthcare Provider Details

I. General information

NPI: 1659135960
Provider Name (Legal Business Name): JENNA LOUISE MACKIE CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2024
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

682 PLEASANT DR
WARREN PA
16365-3499
US

IV. Provider business mailing address

415 W GOLF RD STE 26
ARLINGTON HEIGHTS IL
60005-3923
US

V. Phone/Fax

Practice location:
  • Phone: 855-700-8184
  • Fax:
Mailing address:
  • Phone: 855-700-8184
  • Fax: 224-633-1935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP029049
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: