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General NPI Number Information
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NPI Number | 1942382841
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Entity Type | Individual
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Provider Name | JACQUELINE MCKENZIE M.A.S.M., L.S.W.
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Gender | Female
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Dates
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Enumeration Date | 10/19/2006
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Last Update Date | 01/01/2024
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Provider Practice Location Address
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Address Line | 24 GLENWOOD AVE
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City | DAYTON
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State | OH
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Zip | 45405-3831
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Country | US
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Telephone | 937-814-3573
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Fax | 937-715-4407
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Provider Business Mailing Address
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Address Line | 4455 BROADBUSH DR
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City | TROTWOOD
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State | OH
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Zip | 45426-1905
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Country | US
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Telephone | 937-251-7444
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Fax | 937-715-4407
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | S.0014444
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License Number State | OH
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Taxonomy #3
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | .943876
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License Number State | OH
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