Healthcare Provider Details

I. General information

NPI: 1255760195
Provider Name (Legal Business Name): MRS. JACKIE SUZANNE SHPAK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JACKIE SUZANNE OBERDORF

II. Dates (important events)

Enumeration Date: 11/01/2013
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31275 NORTHWESTERN HWY STE 203
FARMINGTON HILLS MI
48334-2579
US

IV. Provider business mailing address

31275 NORTHWESTERN HWY STE 203
FARMINGTON HILLS MI
48334-2579
US

V. Phone/Fax

Practice location:
  • Phone: 313-583-7422
  • Fax:
Mailing address:
  • Phone: 313-583-7422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301013869
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: