Basic Information
| Provider Information | |||||||||
| NPI: | 1437227386 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHEATLEY | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | SCOTT | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WHEATLEY | ||||||||
| OtherFirstName: | JASON | ||||||||
| OtherMiddleName: | SCOTT | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LISW-S | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1110 ELDON BAKER DR | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485071923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102131803 | ||||||||
| FaxNumber: | 8107441306 | ||||||||
| Practice Location | |||||||||
| Address1: | 1136 WILMINGTON AVENUE | ||||||||
| Address2: | |||||||||
| City: | DEYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372546700 | ||||||||
| FaxNumber: | 9372546776 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 10/30/2013 | ||||||||
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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 | 6801086655 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | I0500089 | OH | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.