Healthcare Provider Details

I. General information

NPI: 1962324848
Provider Name (Legal Business Name): MACKENZIE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 LEE ST
CHARLOTTESVILLE VA
22908-0816
US

IV. Provider business mailing address

210 RESERVE BLVD APT 405
CHARLOTTESVILLE VA
22901-1597
US

V. Phone/Fax

Practice location:
  • Phone: 434-924-3627
  • Fax:
Mailing address:
  • Phone: 803-246-1096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202223750
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: