Provider Demographics
NPI:1275036162
Name:TILLMAN, JASMINE LATRIECE (TLLP, BCBA, LBA)
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:LATRIECE
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:TLLP, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27777 INKSTER RD STE 100
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-5312
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27777 INKSTER RD STE 100
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-5312
Practice Address - Country:US
Practice Address - Phone:248-201-1990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-16
Last Update Date:2025-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7401002219103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI386004894Medicaid