Provider Demographics
NPI:1417476151
Name:CLEMONS, JACQUELYN (LLBSW)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:CLEMONS
Suffix:
Gender:F
Credentials:LLBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9348 TOBINE ST
Mailing Address - Street 2:
Mailing Address - City:ROMULUS
Mailing Address - State:MI
Mailing Address - Zip Code:48174-3365
Mailing Address - Country:US
Mailing Address - Phone:313-285-0156
Mailing Address - Fax:
Practice Address - Street 1:4300 6TH ST
Practice Address - Street 2:
Practice Address - City:ECORSE
Practice Address - State:MI
Practice Address - Zip Code:48229-1110
Practice Address - Country:US
Practice Address - Phone:313-724-6192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-13
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program