Healthcare Provider Details

I. General information

NPI: 1366841637
Provider Name (Legal Business Name): JAZMA ANN WILSON-MILES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2014
Last Update Date: 08/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34050 INDUSTRIAL RD
LIVONIA MI
48150-1306
US

IV. Provider business mailing address

3015 WILLIAMS ST
DEARBORN MI
48124-3786
US

V. Phone/Fax

Practice location:
  • Phone: 734-293-0034
  • Fax: 734-293-0048
Mailing address:
  • Phone: 248-291-4373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number1134203235
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: