Healthcare Provider Details

I. General information

NPI: 1083947832
Provider Name (Legal Business Name): JASON MICHAEL GILLIAM LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2009
Last Update Date: 11/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12990 ONTONAGON DR
DEWITT MI
48820-8658
US

IV. Provider business mailing address

12990 ONTONAGON DR
DEWITT MI
48820-8658
US

V. Phone/Fax

Practice location:
  • Phone: 517-202-3022
  • Fax:
Mailing address:
  • Phone: 517-202-3022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801096929
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: