Provider Demographics
NPI:1316071442
Name:WILKINSON, JASON DEAN (LPC, MA LLP)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:DEAN
Last Name:WILKINSON
Suffix:
Gender:M
Credentials:LPC, MA LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 MACK BLVD, SUITE 2 WEST, CREDENTIALING DEPT.
Mailing Address - Street 2:SUITE 400-CREDENTIALING
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-1138
Mailing Address - Country:US
Mailing Address - Phone:313-448-9006
Mailing Address - Fax:248-906-0463
Practice Address - Street 1:3901 CHRYSLER DR STE 1A
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2167
Practice Address - Country:US
Practice Address - Phone:313-577-1396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401007299103TC0700X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI213119549Medicaid