Basic Information
| Provider Information | |||||||||
| NPI: | 1174183032 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ITRICH | ||||||||
| FirstName: | JASON | ||||||||
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| Credential: | LLMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 805 BROWN ST | ||||||||
| Address2: | |||||||||
| City: | MARINE CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480391742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8105800543 | ||||||||
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| Practice Location | |||||||||
| Address1: | 35455 GARFIELD RD | ||||||||
| Address2: | |||||||||
| City: | CLINTON TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480352236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867925335 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2019 | ||||||||
| LastUpdateDate: | 06/20/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6801104527 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.