Healthcare Provider Details

I. General information

NPI: 1942661269
Provider Name (Legal Business Name): JAIME LUCZAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JAIME NICOLE FRANKS

II. Dates (important events)

Enumeration Date: 03/14/2016
Last Update Date: 03/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24445 NORTHWESTERN HWY SUITE 100
SOUTHFIELD MI
48075-6501
US

IV. Provider business mailing address

738 S BATCHEWANA AVE
CLAWSON MI
48017-1807
US

V. Phone/Fax

Practice location:
  • Phone: 248-483-7804
  • Fax:
Mailing address:
  • Phone: 734-645-3368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801095386
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: