Basic Information
Provider Information | |||||||||
NPI: | 1316071442 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WILKINSON | ||||||||
FirstName: | JASON | ||||||||
MiddleName: | DEAN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC, MA LLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 400 MACK BLVD, SUITE 2 WEST, CREDENTIALING DEPT. | ||||||||
Address2: | SUITE 400-CREDENTIALING | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 482011138 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3134489006 | ||||||||
FaxNumber: | 2489060463 | ||||||||
Practice Location | |||||||||
Address1: | 3901 CHRYSLER DR STE 1A | ||||||||
Address2: |   | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 482012167 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3135771396 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/14/2007 | ||||||||
LastUpdateDate: | 03/25/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/25/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 6401007299 | MI | N |   | Behavioral Health & Social Service Providers | Psychologist | Clinical | 101YP2500X | 6401007299 | MI | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
ID | Type | State | Issuer | Description | 213119549 | 05 | MI |   | MEDICAID |