Provider Demographics
NPI:1992177299
Name:PHILLIPS, JASON DEAN (SUDCC-II 6264)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:DEAN
Last Name:PHILLIPS
Suffix:
Gender:
Credentials:SUDCC-II 6264
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 H ST
Mailing Address - Street 2:
Mailing Address - City:NEEDLES
Mailing Address - State:CA
Mailing Address - Zip Code:92363-2928
Mailing Address - Country:US
Mailing Address - Phone:760-326-4590
Mailing Address - Fax:760-326-3154
Practice Address - Street 1:1600 BAILEY AVE
Practice Address - Street 2:
Practice Address - City:NEEDLES
Practice Address - State:CA
Practice Address - Zip Code:92363-3105
Practice Address - Country:US
Practice Address - Phone:760-326-9321
Practice Address - Fax:760-326-3154
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-26
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)