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General NPI Number Information
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NPI Number | 1871248955
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Entity Type | Individual
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Provider Name | MACKENZIE JARDELL
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Gender | Female
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Dates
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Enumeration Date | 02/16/2022
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Last Update Date | 02/16/2022
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Provider Practice Location Address
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Address Line | 7150 HERITAGE VILLAGE PLZ STE 201
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City | GAINESVILLE
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State | VA
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Zip | 20155-3064
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Country | US
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Telephone | 571-318-9141
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Fax |
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Provider Business Mailing Address
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Address Line | 1131 N UTAH ST
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City | ARLINGTON
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State | VA
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Zip | 22201-5730
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Country | US
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Telephone | 409-719-3456
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 0704014593
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License Number State | VA
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