Provider Demographics
NPI:1770256422
Name:JAKUPCZYK, SHEA MCKENNA (BA)
Entity Type:Individual
Prefix:
First Name:SHEA
Middle Name:MCKENNA
Last Name:JAKUPCZYK
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 ROBEY ST APT J
Mailing Address - Street 2:
Mailing Address - City:RADFORD
Mailing Address - State:VA
Mailing Address - Zip Code:24141-3966
Mailing Address - Country:US
Mailing Address - Phone:518-203-8683
Mailing Address - Fax:
Practice Address - Street 1:705 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-3301
Practice Address - Country:US
Practice Address - Phone:540-588-9582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-28
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAT65138588OtherDRIVERS LICENSE