Provider Demographics
NPI:1982582961
Name:JENUWINE, MACKENZIE LEE
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:LEE
Last Name:JENUWINE
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 1:5425 GULLEN MALL FL 3
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3905
Mailing Address - Country:US
Mailing Address - Phone:586-719-3643
Mailing Address - Fax:
Practice Address - Street 1:3901 CHRYSLER DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2167
Practice Address - Country:US
Practice Address - Phone:313-993-3964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-26
Last Update Date:2025-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362010160103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist