MEDICARE: DR. JACLYN BETH ISSNER PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	6301015380	MI

General Provider Information

NPI Number	:	1679852115
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACLYN BETH ISSNER PH.D.

Provider Business Mailing Address
First Line	:	644 RUFFNER AVE
Second Line	:
City	:	BIRMINGHAM
State	:	MI
Zip	:	48009-1723
Country	:	US
Telephone Number	:	248-909-9801
Fax Number	:

Provider Business Practice Location Address
First Line	:	644 RUFFNER AVE
Second Line	:
City	:	BIRMINGHAM
State	:	MI
Zip	:	48009-1723
Country	:	US
Telephone Number	:	248-909-9801
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/16/2011
Last Update Date	:	05/30/2019

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