Provider Demographics
NPI:1538286471
Name:LISIECKI, JACQUELINE RENE (MSW)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:RENE
Last Name:LISIECKI
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7960 GRAND RIVER RD
Mailing Address - Street 2:120
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48114-7330
Mailing Address - Country:US
Mailing Address - Phone:810-227-1999
Mailing Address - Fax:
Practice Address - Street 1:7960 GRAND RIVER RD
Practice Address - Street 2:120
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114-7330
Practice Address - Country:US
Practice Address - Phone:810-227-1999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010591411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI047108OtherVALUE OPTIONS
MI0890553Medicare ID - Type Unspecified