Healthcare Provider Details

I. General information

NPI: 1124983606
Provider Name (Legal Business Name): MACKENSEY BROOKE JENNINGS CPHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 E STUART DR
GALAX VA
24333-2219
US

IV. Provider business mailing address

80 CONNER LN
GALAX VA
24333-6172
US

V. Phone/Fax

Practice location:
  • Phone: 276-236-3402
  • Fax: 276-236-1426
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number0230044072
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: