Provider Demographics
NPI:1164844171
Name:LOTT, JACLYN SUZANN
Entity Type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:SUZANN
Last Name:LOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2280 E GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48843-8503
Mailing Address - Country:US
Mailing Address - Phone:517-546-4126
Mailing Address - Fax:517-546-1300
Practice Address - Street 1:2280 E GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-8503
Practice Address - Country:US
Practice Address - Phone:517-546-4126
Practice Address - Fax:517-546-1300
Is Sole Proprietor?:No
Enumeration Date:2014-01-09
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010938331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical