Provider Demographics
NPI:1023385481
Name:JANNAKOS, PAUL
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:JANNAKOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2325 W SHIAWASSEE AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-1792
Mailing Address - Country:US
Mailing Address - Phone:810-629-2500
Mailing Address - Fax:
Practice Address - Street 1:2325 W SHIAWASSEE AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-1792
Practice Address - Country:US
Practice Address - Phone:810-965-8670
Practice Address - Fax:810-213-0132
Is Sole Proprietor?:No
Enumeration Date:2011-11-29
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL118310101YP2500X, 101YA0400X, 106H00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health