Basic Information
| Provider Information | |||||||||
| NPI: | 1538413000 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JARVIS | ||||||||
| FirstName: | JASON | ||||||||
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| Credential: | LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6549 TOWN CENTER DR STE A | ||||||||
| Address2: | |||||||||
| City: | CLARKSTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483464824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486206400 | ||||||||
| FaxNumber: | 2486206405 | ||||||||
| Practice Location | |||||||||
| Address1: | 2401 S LINDEN RD | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8109574310 | ||||||||
| FaxNumber: | 8109574309 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2012 | ||||||||
| LastUpdateDate: | 04/30/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 6301015258 | MI | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 6361006732 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103T00000X | 6301015258 | MI | N | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.