Provider Demographics
NPI:1083947832
Name:GILLIAM, JASON MICHAEL (LMSW)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:MICHAEL
Last Name:GILLIAM
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12990 ONTONAGON DR
Mailing Address - Street 2:
Mailing Address - City:DEWITT
Mailing Address - State:MI
Mailing Address - Zip Code:48820-8658
Mailing Address - Country:US
Mailing Address - Phone:517-202-3022
Mailing Address - Fax:
Practice Address - Street 1:12990 ONTONAGON DR
Practice Address - Street 2:
Practice Address - City:DEWITT
Practice Address - State:MI
Practice Address - Zip Code:48820-8658
Practice Address - Country:US
Practice Address - Phone:517-202-3022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-11
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010969291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical