=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417476151
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACQUELYN CLEMONS LLBSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2017
-----------------------------------------------------
Last Update Date | 09/13/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4300 6TH ST
-----------------------------------------------------
City | ECORSE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48229-1110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-724-6192
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9348 TOBINE ST
-----------------------------------------------------
City | ROMULUS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48174-3365
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-285-0156
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------