Provider Demographics
NPI:1366089278
Name:JORDAN, MACKENZIE
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:JORDAN
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 1:625 MOUNT AUBURN ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-4555
Mailing Address - Country:US
Mailing Address - Phone:781-551-0999
Mailing Address - Fax:
Practice Address - Street 1:625 MOUNT AUBURN ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-4555
Practice Address - Country:US
Practice Address - Phone:781-551-0999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-10
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPSY10000234103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical