Provider Demographics
NPI:1053985838
Name:SUMMERLIN, JACQUELYN DIANE
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:DIANE
Last Name:SUMMERLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 W. MILWAUKEE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202
Mailing Address - Country:US
Mailing Address - Phone:313-344-9099
Mailing Address - Fax:
Practice Address - Street 1:740 W. MILWAUKEE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202
Practice Address - Country:US
Practice Address - Phone:313-344-9099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-17
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801015744101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health