Provider Demographics
NPI:1255760195
Name:SHPAK, JACKIE SUZANNE
Entity type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:SUZANNE
Last Name:SHPAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:SUZANNE
Other - Last Name:OBERDORF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2149 JOLLY RD
Mailing Address - Street 2:STE 500
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864
Mailing Address - Country:US
Mailing Address - Phone:517-347-4645
Mailing Address - Fax:517-347-4644
Practice Address - Street 1:2149 JOLLY RD
Practice Address - Street 2:STE 500
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864
Practice Address - Country:US
Practice Address - Phone:517-347-4645
Practice Address - Fax:517-347-4644
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-01
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013869103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical