Provider Demographics
NPI:1811087125
Name:SPACKMAN, JENNIFER MODE (PSYD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:MODE
Last Name:SPACKMAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 BRADFORD AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28301-5401
Mailing Address - Country:US
Mailing Address - Phone:910-829-9017
Mailing Address - Fax:910-485-4752
Practice Address - Street 1:109 BRADFORD AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-5401
Practice Address - Country:US
Practice Address - Phone:910-488-2120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-15
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5201103TC0700X
UT271874-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical