Provider Demographics
NPI:1932714615
Name:SCIMEMI, JASON MARK (TLLP)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:MARK
Last Name:SCIMEMI
Suffix:
Gender:M
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 RAMSGATE RD APT 4
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3122
Mailing Address - Country:US
Mailing Address - Phone:248-977-0137
Mailing Address - Fax:
Practice Address - Street 1:1309 S LINDEN RD STE C
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:810-630-1152
Practice Address - Fax:810-630-9107
Is Sole Proprietor?:No
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362009222103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist