Provider Demographics
NPI:1366841637
Name:WILSON-MILES, JAZMA ANN
Entity Type:Individual
Prefix:
First Name:JAZMA
Middle Name:ANN
Last Name:WILSON-MILES
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 1:3015 WILLIAMS ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-3786
Mailing Address - Country:US
Mailing Address - Phone:248-291-4373
Mailing Address - Fax:
Practice Address - Street 1:34050 INDUSTRIAL RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-1306
Practice Address - Country:US
Practice Address - Phone:734-293-0034
Practice Address - Fax:734-293-0048
Is Sole Proprietor?:No
Enumeration Date:2014-08-22
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1134203235103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities