Provider Demographics
NPI:1447480215
Name:MACKENZIE, LACEY JILL (LPC)
Entity type:Individual
Prefix:MS
First Name:LACEY
Middle Name:JILL
Last Name:MACKENZIE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1233 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:WEISER
Mailing Address - State:ID
Mailing Address - Zip Code:83672-1533
Mailing Address - Country:US
Mailing Address - Phone:208-739-0982
Mailing Address - Fax:
Practice Address - Street 1:1219 SW 4TH AVE UNIT 1
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-4500
Practice Address - Country:US
Practice Address - Phone:541-889-2668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-15
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC- 4348101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health