Provider Demographics
NPI:1275053241
Name:BETTS, JACK EUGENE (MA, LPC)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:EUGENE
Last Name:BETTS
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18045 MUIRLAND ST.
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-2754
Mailing Address - Country:US
Mailing Address - Phone:313-862-0568
Mailing Address - Fax:
Practice Address - Street 1:43630 HAYES RD STE 120
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-3536
Practice Address - Country:US
Practice Address - Phone:586-412-1510
Practice Address - Fax:586-412-1508
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-21
Last Update Date:2017-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401000234101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty