Healthcare Provider Details

I. General information

NPI: 1326103771
Provider Name (Legal Business Name): AMY JAK PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY WISE

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 04/09/2026
Certification Date: 04/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 E EISENHOWER PKWY
ANN ARBOR MI
48108-3364
US

IV. Provider business mailing address

3621 S STATE ST
ANN ARBOR MI
48108-1633
US

V. Phone/Fax

Practice location:
  • Phone: 734-936-7175
  • Fax:
Mailing address:
  • Phone: 734-647-5299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number21113
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301019762
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: