Provider Demographics
NPI:1063565455
Name:JIRAK, JEFFREY S (LPC, LISAC)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:S
Last Name:JIRAK
Suffix:
Gender:M
Credentials:LPC, LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7500 N DREAMY DRAW DR STE 145
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-4668
Mailing Address - Country:US
Mailing Address - Phone:480-882-4545
Mailing Address - Fax:480-882-5814
Practice Address - Street 1:11851 N 51ST AVE STE B110
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-2823
Practice Address - Country:US
Practice Address - Phone:480-882-4545
Practice Address - Fax:623-773-2267
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-10590101YA0400X
AZLPC-2320101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ646316Medicaid