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General NPI Number Information
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NPI Number | 1467331306
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Entity Type | Individual
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Provider Name | JASON E BANIUKAITIS MA, TLLP
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Gender | Male
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Dates
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Enumeration Date | 08/27/2025
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Last Update Date | 08/27/2025
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Provider Practice Location Address
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Address Line | 7195 THORNAPPLE RIVER DR SE STE C
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City | ADA
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State | MI
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Zip | 49301-8411
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Country | US
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Telephone | 616-929-0248
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Fax |
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Provider Business Mailing Address
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Address Line | 4165 REX VALLEY DR NE
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City | ROCKFORD
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State | MI
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Zip | 49341-8511
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Country | US
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Telephone | 616-826-3045
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number | 6362010197
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License Number State | MI
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