Provider Demographics
NPI:1720249386
Name:LOVELACE, JAQUITA
Entity Type:Individual
Prefix:MS
First Name:JAQUITA
Middle Name:
Last Name:LOVELACE
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 1:620 HAWKSMOORE DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48348-3628
Mailing Address - Country:US
Mailing Address - Phone:248-224-9772
Mailing Address - Fax:586-884-6552
Practice Address - Street 1:7800 W OUTER DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-3461
Practice Address - Country:US
Practice Address - Phone:313-362-9445
Practice Address - Fax:313-362-0444
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201006278225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist