Provider Demographics
NPI:1245417286
Name:VORPAHL, JACQUELINE MELLISSA (PHD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MELLISSA
Last Name:VORPAHL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:258 MAIN ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:MEDFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02052-2041
Mailing Address - Country:US
Mailing Address - Phone:508-242-9666
Mailing Address - Fax:815-572-8941
Practice Address - Street 1:258 MAIN ST
Practice Address - Street 2:SUITE 3
Practice Address - City:MEDFIELD
Practice Address - State:MA
Practice Address - Zip Code:02052-2041
Practice Address - Country:US
Practice Address - Phone:508-242-9666
Practice Address - Fax:815-572-8941
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-22
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7426103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAVOW51242Medicare PIN