Provider Demographics
NPI:1730529405
Name:STARKS-MENTOR, JACQUELYN (LLMSW)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:STARKS-MENTOR
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 746723
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6723
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:
Practice Address - Street 1:18610 FENKELL ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-2378
Practice Address - Country:US
Practice Address - Phone:313-723-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-26
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010940841041C0700X, 171M00000X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator