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General NPI Number Information
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NPI Number | 1265282123
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Entity Type | Individual
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Provider Name | LUCILE JAYNE CLARK LLC
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Gender | Female
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Dates
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Enumeration Date | 03/25/2024
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Last Update Date | 07/22/2025
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Provider Practice Location Address
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Address Line | 3121 UNIVERSITY DR STE 140
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City | AUBURN HILLS
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State | MI
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Zip | 48326-4606
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Country | US
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Telephone | 248-923-2099
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Fax |
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Provider Business Mailing Address
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Address Line | 7598 RING NECK DR
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City | WATERFORD
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State | MI
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Zip | 48327-4335
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Country | US
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Telephone | 541-890-6941
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 6451023284
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License Number State | MI
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