Provider Demographics
NPI:1316282742
Name:JONES, PHYLLIS KAY (LPC, NCC, CADC-M)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:KAY
Last Name:JONES
Suffix:
Gender:F
Credentials:LPC, NCC, CADC-M
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29828 CHELMSFORD RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-5703
Mailing Address - Country:US
Mailing Address - Phone:248-215-2658
Mailing Address - Fax:
Practice Address - Street 1:29828 CHELMSFORD RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-5703
Practice Address - Country:US
Practice Address - Phone:248-215-2658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-12
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013355101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1316282742Medicaid