Provider Demographics
NPI:1942661269
Name:LUCZAK, JAIME
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:
Last Name:LUCZAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JAIME
Other - Middle Name:NICOLE
Other - Last Name:FRANKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:738 S BATCHEWANA AVE
Mailing Address - Street 2:
Mailing Address - City:CLAWSON
Mailing Address - State:MI
Mailing Address - Zip Code:48017-1807
Mailing Address - Country:US
Mailing Address - Phone:734-645-3368
Mailing Address - Fax:
Practice Address - Street 1:24445 NORTHWESTERN HWY
Practice Address - Street 2:SUITE 100
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-6501
Practice Address - Country:US
Practice Address - Phone:248-483-7804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-14
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010953861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical