Active NPI
Jennifer Mode Spackman, PSY.D.
- Clinical Psychologist
- Fayetteville, NC
National Provider Identifier
1811087125
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- 271874-2501
- Practice address
- 109 Bradford Ave
Fayetteville, NC 28301-5401 - Phone
- (910) 488-2120
- NPI assigned
- Oct 15, 2006
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | 5201 | NC | |
| Clinical Psychologist | 103TC0700X | 271874-2501 | UT | Primary |
Addresses
Primary practice location
109 Bradford Ave
Fayetteville, NC 28301-5401
Mailing address
109 Bradford Ave
Fayetteville, NC 28301-5401
Phone (910) 829-9017
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 271874-2501 | UT | MD | Clinical Psychologist |
| 5201 | NC | MD | General Practice Dentistry |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1160870400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1560384000000",
"number": "1811087125",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "109 BRADFORD AVE",
"city": "FAYETTEVILLE",
"state": "NC",
"postal_code": "283015401",
"telephone_number": "910-829-9017",
"fax_number": "910-485-4752"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "109 BRADFORD AVE",
"city": "FAYETTEVILLE",
"state": "NC",
"postal_code": "283015401",
"telephone_number": "910-488-2120"
}
],
"practiceLocations": [],
"basic": {
"last_name": "SPACKMAN",
"first_name": "JENNIFER",
"middle_name": "MODE",
"name_prefix": "Dr.",
"credential": "PSY.D.",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2006-10-15",
"last_updated": "2019-06-13",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "NC",
"license": "5201",
"primary": false
},
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "UT",
"license": "271874-2501",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Fayetteville, NC
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 13, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.