Provider Demographics
NPI:1326699182
Name:WITUCKI, JAIMMIE ILANA (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:JAIMMIE
Middle Name:ILANA
Last Name:WITUCKI
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MISS
Other - First Name:JAIMMIE
Other - Middle Name:ILANA
Other - Last Name:KOSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:23741 REYNOLDS AVE
Mailing Address - Street 2:
Mailing Address - City:HAZEL PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48030-1448
Mailing Address - Country:US
Mailing Address - Phone:248-798-2538
Mailing Address - Fax:
Practice Address - Street 1:625 E BIG BEAVER RD STE 200
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-1434
Practice Address - Country:US
Practice Address - Phone:586-863-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-24
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011054881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical