Provider Demographics
NPI:1467331306
Name:BANIUKAITIS, JASON E (MA, TLLP)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:E
Last Name:BANIUKAITIS
Suffix:
Gender:M
Credentials:MA, TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4165 REX VALLEY DR NE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-8511
Mailing Address - Country:US
Mailing Address - Phone:616-826-3045
Mailing Address - Fax:
Practice Address - Street 1:7195 THORNAPPLE RIVER DR SE STE C
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:MI
Practice Address - Zip Code:49301-8411
Practice Address - Country:US
Practice Address - Phone:616-929-0248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-27
Last Update Date:2025-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362010197103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling