Healthcare Provider Details

I. General information

NPI: 1912443482
Provider Name (Legal Business Name): JASPER H WURSTER LCPC, LPC
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2017
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1518 E LINCOLN AVE
ROYAL OAK MI
48067-3402
US

IV. Provider business mailing address

949 W FARNUM AVE
MADISON HEIGHTS MI
48071-3107
US

V. Phone/Fax

Practice location:
  • Phone: 248-677-1502
  • Fax: 313-789-1664
Mailing address:
  • Phone: 248-677-1502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180.011626
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401223373
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: