Provider Demographics
NPI:1053118406
Name:JOHNSON, MACKENZIE
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 MAIDEN LN
Mailing Address - Street 2:
Mailing Address - City:PLEASANT LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49272-9773
Mailing Address - Country:US
Mailing Address - Phone:517-240-5359
Mailing Address - Fax:
Practice Address - Street 1:1111 W GANSON ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-4208
Practice Address - Country:US
Practice Address - Phone:800-653-4077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-25
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician