Healthcare Provider Details

I. General information

NPI: 1427602531
Provider Name (Legal Business Name): JACKIE LAVETE LUCAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2019
Last Update Date: 07/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19270 RED MAPLE CT
SOUTHFIELD MI
48076-1006
US

IV. Provider business mailing address

19270 RED MAPLE CT
SOUTHFIELD MI
48076-1006
US

V. Phone/Fax

Practice location:
  • Phone: 248-296-1252
  • Fax:
Mailing address:
  • Phone: 248-296-1252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number4704261129
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: