Healthcare Provider Details

I. General information

NPI: 1538413000
Provider Name (Legal Business Name): JASON JARVIS LLP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2012
Last Update Date: 04/30/2020
Certification Date: 04/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 S LINDEN RD
FLINT MI
48532
US

IV. Provider business mailing address

6549 TOWN CENTER DR STE A
CLARKSTON MI
48346-4824
US

V. Phone/Fax

Practice location:
  • Phone: 810-957-4310
  • Fax: 810-957-4309
Mailing address:
  • Phone: 248-620-6400
  • Fax: 248-620-6405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301015258
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6361006732
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301015258
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: