Healthcare Provider Details

I. General information

NPI: 1467331306
Provider Name (Legal Business Name): JASON E BANIUKAITIS MA, TLLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2025
Last Update Date: 08/27/2025
Certification Date: 08/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7195 THORNAPPLE RIVER DR SE STE C
ADA MI
49301-8411
US

IV. Provider business mailing address

4165 REX VALLEY DR NE
ROCKFORD MI
49341-8511
US

V. Phone/Fax

Practice location:
  • Phone: 616-929-0248
  • Fax:
Mailing address:
  • Phone: 616-826-3045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6362010197
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: