MEDICARE: MACKENZIE JUSTINE NELSON MA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	RIC	VA

General Provider Information

NPI Number	:	1306438718
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MACKENZIE JUSTINE NELSON MA

Provider Business Mailing Address
First Line	:	111 MELBOURNE PARK CIR APT B
Second Line	:
City	:	CHARLOTTESVILLE
State	:	VA
Zip	:	22901-3940
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5793 THE SQ
Second Line	:
City	:	CROZET
State	:	VA
Zip	:	22932-3182
Country	:	US
Telephone Number	:	434-202-4080
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/07/2021
Last Update Date	:	02/07/2021

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Directions to “ MACKENZIE JUSTINE NELSON MA” Practice Location

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