Healthcare Provider Details

I. General information

NPI: 1710525241
Provider Name (Legal Business Name): JASON WILLIAMS N/A
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2019
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20303 KELLY RD
DETROIT MI
48225-1206
US

IV. Provider business mailing address

2900 CONNER ST
DETROIT MI
48215-2407
US

V. Phone/Fax

Practice location:
  • Phone: 313-245-7000
  • Fax:
Mailing address:
  • Phone: 313-308-1400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: