Provider Demographics
NPI:1942326087
Name:SOULIA, JESSE (PSYD)
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:
Last Name:SOULIA
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 S LINDEN RD STE D
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3443
Mailing Address - Country:US
Mailing Address - Phone:810-732-6111
Mailing Address - Fax:810-732-6185
Practice Address - Street 1:1309 S LINDEN RD STE D
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3443
Practice Address - Country:US
Practice Address - Phone:810-732-6111
Practice Address - Fax:810-732-6185
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006715103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI266250000OtherMAGELLAN
MI680B546150OtherBLUE CROSS MICHIGAN
MI680B546150OtherBLUE CROSS MICHIGAN