Healthcare Provider Details

I. General information

NPI: 1770913832
Provider Name (Legal Business Name): JAMIE WILSON LLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2013
Last Update Date: 09/18/2022
Certification Date: 09/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5001 PLAINFIELD AVE NE STE B
GRAND RAPIDS MI
49525-1050
US

IV. Provider business mailing address

5001 PLAINFIELD AVE NE STE B
GRAND RAPIDS MI
49525-1050
US

V. Phone/Fax

Practice location:
  • Phone: 616-600-1667
  • Fax:
Mailing address:
  • Phone: 616-600-1667
  • Fax: 616-805-3613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6361004924
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301015678
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number6301015678
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6301015678
License Number StateMI
# 5
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6301015678
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: