Provider Demographics
NPI:1871316224
Name:SMITH, JASON ANDREW (MA TLLP LLPC)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:ANDREW
Last Name:SMITH
Suffix:
Gender:M
Credentials:MA TLLP LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11536 ASPEN DR
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-4597
Mailing Address - Country:US
Mailing Address - Phone:734-347-6562
Mailing Address - Fax:
Practice Address - Street 1:496 W ANN ARBOR TRL STE 101
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-6262
Practice Address - Country:US
Practice Address - Phone:734-347-6562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451023628101Y00000X
MI6362009926103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor