Provider Demographics
NPI:1942614227
Name:JACKINCHUK, LISA MARIE (LMSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:JACKINCHUK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EATON RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:48827-1952
Mailing Address - Country:US
Mailing Address - Phone:517-663-2671
Mailing Address - Fax:517-663-9436
Practice Address - Street 1:1500 S MAIN ST
Practice Address - Street 2:
Practice Address - City:EATON RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:48827-1952
Practice Address - Country:US
Practice Address - Phone:517-663-2671
Practice Address - Fax:517-663-9436
Is Sole Proprietor?:No
Enumeration Date:2014-06-16
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010867341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical