Basic Information
| Provider Information | |||||||||
| NPI: | 1932714615 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SCIMEMI | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | MARK | ||||||||
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| Credential: | TLLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1109 RAMSGATE RD APT 4 | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485323122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489770137 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1309 S LINDEN RD STE C | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485323443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8106301152 | ||||||||
| FaxNumber: | 8106309107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2020 | ||||||||
| LastUpdateDate: | 09/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 6362009222 | MI | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.