Provider Demographics
NPI:1174183032
Name:ITRICH, JASON (LLMSW)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:ITRICH
Suffix:
Gender:M
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 BROWN ST
Mailing Address - Street 2:
Mailing Address - City:MARINE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48039-1742
Mailing Address - Country:US
Mailing Address - Phone:810-580-0543
Mailing Address - Fax:
Practice Address - Street 1:35455 GARFIELD RD
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48035-2236
Practice Address - Country:US
Practice Address - Phone:586-792-5335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-13
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801104527104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker