Healthcare Provider Details

I. General information

NPI: 1417861816
Provider Name (Legal Business Name): JACEY ANTCLIFF
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1013 S US HIGHWAY 27 STE A
SAINT JOHNS MI
48879-2423
US

IV. Provider business mailing address

4459 W GRAND RIVER RD
OWOSSO MI
48867-9290
US

V. Phone/Fax

Practice location:
  • Phone: 989-224-6831
  • Fax:
Mailing address:
  • Phone: 989-640-8084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6851119311
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: