Provider Demographics
NPI:1366594947
Name:RADIN, JAY JACOB (PHD)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:JACOB
Last Name:RADIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 FULLER COURT
Mailing Address - Street 2:SUITE 1106B
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105
Mailing Address - Country:US
Mailing Address - Phone:734-996-4247
Mailing Address - Fax:734-665-2440
Practice Address - Street 1:2200 FULLER COURT
Practice Address - Street 2:SUITE 1106B
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105
Practice Address - Country:US
Practice Address - Phone:734-996-4247
Practice Address - Fax:734-665-2440
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI002469103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH14589Medicare ID - Type Unspecified