Provider Demographics
NPI:1619168572
Name:OLIPHANT, JACQUELYN (PHD)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:OLIPHANT
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 1:143 CADYCENTRE
Mailing Address - Street 2:#206
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-1119
Mailing Address - Country:US
Mailing Address - Phone:248-924-2133
Mailing Address - Fax:248-924-2599
Practice Address - Street 1:725 S ADAMS RD
Practice Address - Street 2:SUITE 241
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-6902
Practice Address - Country:US
Practice Address - Phone:248-924-2133
Practice Address - Fax:248-924-2599
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005964103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist