Provider Demographics
NPI:1053336149
Name:SCHAEFER, JACK PHILLIP
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:PHILLIP
Last Name:SCHAEFER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4313 W MARKHAM ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-4023
Mailing Address - Country:US
Mailing Address - Phone:501-686-9406
Mailing Address - Fax:501-686-9276
Practice Address - Street 1:4313 W MARKHAM ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-4023
Practice Address - Country:US
Practice Address - Phone:501-686-9406
Practice Address - Fax:501-686-9276
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR94-30P103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical