Provider Demographics
NPI:1902344773
Name:MCKENZIE, JELLY
Entity Type:Individual
Prefix:
First Name:JELLY
Middle Name:
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 CHELCIE ST
Mailing Address - Street 2:
Mailing Address - City:FALLON
Mailing Address - State:NV
Mailing Address - Zip Code:89406-8263
Mailing Address - Country:US
Mailing Address - Phone:775-423-0197
Mailing Address - Fax:
Practice Address - Street 1:295 E WILLIAMS AVE
Practice Address - Street 2:
Practice Address - City:FALLON
Practice Address - State:NV
Practice Address - Zip Code:89406-3020
Practice Address - Country:US
Practice Address - Phone:775-867-5615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-01
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health