Provider Demographics
NPI:1073912580
Name:HACKENBERG, JESSICA LYNN (PSYD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:HACKENBERG
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53931 WILBUR RD
Mailing Address - Street 2:
Mailing Address - City:THREE RIVERS
Mailing Address - State:MI
Mailing Address - Zip Code:49093-9765
Mailing Address - Country:US
Mailing Address - Phone:812-841-1448
Mailing Address - Fax:
Practice Address - Street 1:2121 LAKE AVE
Practice Address - Street 2:116A-M
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5100
Practice Address - Country:US
Practice Address - Phone:765-674-3321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-20
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6646103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical