Provider Demographics
NPI:1164528246
Name:JAGACKI, KARISSA L (AUD,CCC-A)
Entity Type:Individual
Prefix:DR
First Name:KARISSA
Middle Name:L
Last Name:JAGACKI
Suffix:
Gender:F
Credentials:AUD,CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20956 OAK TREE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-7068
Mailing Address - Country:US
Mailing Address - Phone:248-444-0674
Mailing Address - Fax:734-467-5100
Practice Address - Street 1:35337 WARREN RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-2013
Practice Address - Country:US
Practice Address - Phone:734-467-5100
Practice Address - Fax:734-467-5103
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000113237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI640H227530OtherBCBS-SERVICES
MI4704347Medicaid
MI540H104260OtherBCBS-HEARING AIDS
MI4433772Medicaid
MI0H10426OtherBLUE CARE NETWORK PIN
MI0N56970Medicare PIN