Provider Demographics
NPI:1679852115
Name:ISSNER, JACLYN BETH (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACLYN
Middle Name:BETH
Last Name:ISSNER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:JACKIE
Other - Middle Name:BETH
Other - Last Name:HELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:644 RUFFNER AVE
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-1723
Mailing Address - Country:US
Mailing Address - Phone:248-909-9801
Mailing Address - Fax:
Practice Address - Street 1:644 RUFFNER AVE
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-1723
Practice Address - Country:US
Practice Address - Phone:248-909-9801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-16
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015380103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical