Provider Demographics
NPI:1356508295
Name:SKILLINGS, JARED LYON (PHD)
Entity Type:Individual
Prefix:DR
First Name:JARED
Middle Name:LYON
Last Name:SKILLINGS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:330 BARCLAY AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2556
Practice Address - Country:US
Practice Address - Phone:616-391-2802
Practice Address - Fax:616-391-2840
Is Sole Proprietor?:No
Enumeration Date:2008-05-19
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013341103TH0100X, 103TA0700X, 103TB0200X, 103T00000X, 103TC0700X, 103TF0000X, 103TH0004X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1356508295Medicaid
MIM74460745Medicare PIN