Provider Demographics
NPI:1275036162
Name:TILLMAN, JASMINE LATRIECE
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:LATRIECE
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19853 OUTER DR STE 110
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2044
Mailing Address - Country:US
Mailing Address - Phone:313-406-5056
Mailing Address - Fax:248-712-4381
Practice Address - Street 1:19853 OUTER DR STE 110
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2044
Practice Address - Country:US
Practice Address - Phone:313-406-5056
Practice Address - Fax:248-712-4381
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-16
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7402000124106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI386004894Medicaid