Provider Demographics
NPI:1841463676
Name:SOVA, JACQUELINE MARLENE (LLP)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:MARLENE
Last Name:SOVA
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13275 LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-1019
Mailing Address - Country:US
Mailing Address - Phone:810-629-3882
Mailing Address - Fax:
Practice Address - Street 1:1409 S GRAHAM RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3538
Practice Address - Country:US
Practice Address - Phone:810-217-1024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-14
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013661101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health