Provider Demographics
NPI:1669262978
Name:METTIE, JASON MICHAEL (LPN)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:MICHAEL
Last Name:METTIE
Suffix:
Gender:
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4540 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:LUNA PIER
Mailing Address - State:MI
Mailing Address - Zip Code:48157-9735
Mailing Address - Country:US
Mailing Address - Phone:734-735-1972
Mailing Address - Fax:
Practice Address - Street 1:3250 N MONROE ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-9297
Practice Address - Country:US
Practice Address - Phone:734-384-3402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-09
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703106042164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse