Basic Information
| Provider Information | |||||||||
| NPI: | 1326296922 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MACKOWIAK | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7 N ERIE ST | ||||||||
| Address2: | |||||||||
| City: | MAYVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147571090 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7167534104 | ||||||||
| FaxNumber: | 7167534230 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 E 3RD ST | ||||||||
| Address2: | 5TH FLOOR MUNICIPAL BUILDING | ||||||||
| City: | JAMESTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147015433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166618330 | ||||||||
| FaxNumber: | 7167534230 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2008 | ||||||||
| LastUpdateDate: | 08/18/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101YA0400X | P75686 | NY | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.