Healthcare Provider Details

I. General information

NPI: 1265282123
Provider Name (Legal Business Name): LUCILE JAYNE CLARK LLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LUCI CLARK

II. Dates (important events)

Enumeration Date: 03/25/2024
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3121 UNIVERSITY DR STE 140
AUBURN HILLS MI
48326-4606
US

IV. Provider business mailing address

7598 RING NECK DR
WATERFORD MI
48327-4335
US

V. Phone/Fax

Practice location:
  • Phone: 248-923-2099
  • Fax:
Mailing address:
  • Phone: 541-890-6941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6451023284
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: