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General NPI Number Information
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NPI Number | 1912409624
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Entity Type | Individual
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Provider Name | JACOB MCKENZIE
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Gender | Male
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Dates
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Enumeration Date | 03/08/2018
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Last Update Date | 07/04/2018
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Provider Practice Location Address
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Address Line | 1340 HAL GREER BLVD
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City | HUNTINGTON
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State | WV
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Zip | 25701
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Country | US
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Telephone | 304-638-9517
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Fax |
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Provider Business Mailing Address
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Address Line | 2725 ROUTE 75
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City | KENOVA
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State | WV
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Zip | 25530-9793
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Country | US
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Telephone | 304-638-9517
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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 | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | APRN79908CRNA
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License Number State | WV
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