Provider Demographics
NPI:1669715637
Name:WITHERELL, JAY STEPHEN (PHD)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:STEPHEN
Last Name:WITHERELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41740 W VILLAGE GREEN BLVD
Mailing Address - Street 2:APT. 204
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-5318
Mailing Address - Country:US
Mailing Address - Phone:419-349-1050
Mailing Address - Fax:
Practice Address - Street 1:8303 PLATT RD
Practice Address - Street 2:
Practice Address - City:SALINE
Practice Address - State:MI
Practice Address - Zip Code:48176-9773
Practice Address - Country:US
Practice Address - Phone:734-429-2531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-28
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015464103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical