Provider Demographics
NPI:1902930944
Name:MACKINNON, JENNIFER A
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:MACKINNON
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 1:9343 TECH CENTER DR
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95826-2563
Mailing Address - Country:US
Mailing Address - Phone:916-388-6400
Mailing Address - Fax:916-649-7158
Practice Address - Street 1:9343 TECH CENTER DR
Practice Address - Street 2:#200
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95826
Practice Address - Country:US
Practice Address - Phone:916-388-6344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA109180106H00000X
CA63449106H00000X
CA93029106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist