Provider Demographics
NPI:1023222320
Name:LEWIS, JACQUELYNE (LBSW, LLPC)
Entity Type:Individual
Prefix:
First Name:JACQUELYNE
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:LBSW, LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 WOODWARD AVE
Mailing Address - Street 2:STE 600
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2061
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2751 E JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-4180
Practice Address - Country:US
Practice Address - Phone:313-993-3434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401006679101Y00000X
MI6802080467104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker