Healthcare Provider Details

I. General information

NPI: 1932714615
Provider Name (Legal Business Name): JASON MARK SCIMEMI TLLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2020
Last Update Date: 09/10/2020
Certification Date: 09/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1309 S LINDEN RD STE C
FLINT MI
48532-3443
US

IV. Provider business mailing address

1109 RAMSGATE RD APT 4
FLINT MI
48532-3122
US

V. Phone/Fax

Practice location:
  • Phone: 810-630-1152
  • Fax: 810-630-9107
Mailing address:
  • Phone: 248-977-0137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6362009222
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: