Provider Demographics
NPI:1437227386
Name:WHEATLEY, JASON SCOTT (LMSW)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:SCOTT
Last Name:WHEATLEY
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:MR
Other - First Name:JASON
Other - Middle Name:SCOTT
Other - Last Name:WHEATLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LISW-S
Mailing Address - Street 1:1110 ELDON BAKER DR
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-1923
Mailing Address - Country:US
Mailing Address - Phone:810-213-1803
Mailing Address - Fax:810-744-1306
Practice Address - Street 1:1136 WILMINGTON AVENUE
Practice Address - Street 2:
Practice Address - City:DEYTON
Practice Address - State:OH
Practice Address - Zip Code:45420
Practice Address - Country:US
Practice Address - Phone:937-254-6700
Practice Address - Fax:937-254-6776
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801086655104100000X
OHI05000891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical