Provider Demographics
NPI:1770913832
Name:WILSON, JAMIE (LLP)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5001 PLAINFIELD AVE NE STE B
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-1050
Mailing Address - Country:US
Mailing Address - Phone:616-600-1667
Mailing Address - Fax:616-805-3613
Practice Address - Street 1:5001 PLAINFIELD AVE NE STE B
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-1050
Practice Address - Country:US
Practice Address - Phone:616-600-1667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-26
Last Update Date:2022-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361004924103T00000X
MI6301015678103T00000X, 103TA0700X, 103TC1900X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1770913832Medicaid