Basic Information
| Provider Information | |||||||||
| NPI: | 1619498235 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POBLACION | ||||||||
| FirstName: | JASON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1370 N OAKLAND BLVD STE 105 | ||||||||
| Address2: | |||||||||
| City: | WATERFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483271572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486668870 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1370 N OAKLAND BLVD STE 105 | ||||||||
| Address2: | |||||||||
| City: | WATERFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483271572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486668870 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6401016154 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.