Provider Demographics
NPI:1063040863
Name:MOTT, JASON ROY
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:ROY
Last Name:MOTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1806 HAMILTON RD APT B2
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-5808
Mailing Address - Country:US
Mailing Address - Phone:702-469-4167
Mailing Address - Fax:
Practice Address - Street 1:2970 E LAKE LANSING RD
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-7415
Practice Address - Country:US
Practice Address - Phone:517-230-5695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-29
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401017823101YM0800X
MI6401223673101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health