Provider Demographics
NPI:1821460270
Name:HAMLIN, JACLYN (MSCP, TLLP)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:HAMLIN
Suffix:
Gender:F
Credentials:MSCP, TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31219 ARROWHEAD ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48082-1208
Mailing Address - Country:US
Mailing Address - Phone:248-275-9067
Mailing Address - Fax:
Practice Address - Street 1:25501 VAN DYKE AVE
Practice Address - Street 2:LIFELINE PSYCHIATRIC SERVICES
Practice Address - City:CENTER LINE
Practice Address - State:MI
Practice Address - Zip Code:48015-1208
Practice Address - Country:US
Practice Address - Phone:586-755-8911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-26
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016375103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI13642807OtherCAQH
MI630106375OtherPSYCHOLOGIST TEMPORARY LIMITED LICENSE