Provider Demographics
NPI:1427602531
Name:LUCAS, JACKIE LAVETE
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:LAVETE
Last Name:LUCAS
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 1:19270 RED MAPLE CT
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-1006
Mailing Address - Country:US
Mailing Address - Phone:248-296-1252
Mailing Address - Fax:
Practice Address - Street 1:19270 RED MAPLE CT
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-1006
Practice Address - Country:US
Practice Address - Phone:248-296-1252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-26
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704261129163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator