Provider Demographics
NPI:1598509119
Name:PHILLIPS, JASON RAY
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:RAY
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1858 MIDDLE FORK RD
Mailing Address - Street 2:
Mailing Address - City:KENNA
Mailing Address - State:WV
Mailing Address - Zip Code:25248-6049
Mailing Address - Country:US
Mailing Address - Phone:304-373-4894
Mailing Address - Fax:
Practice Address - Street 1:1858 MIDDLE FORK RD
Practice Address - Street 2:
Practice Address - City:KENNA
Practice Address - State:WV
Practice Address - Zip Code:25248-6049
Practice Address - Country:US
Practice Address - Phone:304-373-4894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-19
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant