Healthcare Provider Details

I. General information

NPI: 1992177299
Provider Name (Legal Business Name): JASON DEAN PHILLIPS SUDCC-II 6264
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2015
Last Update Date: 02/19/2025
Certification Date: 02/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 BAILEY AVE
NEEDLES CA
92363-3105
US

IV. Provider business mailing address

300 H ST
NEEDLES CA
92363-2928
US

V. Phone/Fax

Practice location:
  • Phone: 760-326-9321
  • Fax: 760-326-3154
Mailing address:
  • Phone: 760-326-4590
  • Fax: 760-326-3154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: