Healthcare Provider Details

I. General information

NPI: 1962334219
Provider Name (Legal Business Name): AMANDA JESSICA PHILLIPS ACD.0002692
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

443 HIGHWAY 105
PALMER LAKE CO
80133-9003
US

IV. Provider business mailing address

1383 LAKELAND GRV APT 306
MONUMENT CO
80132-6255
US

V. Phone/Fax

Practice location:
  • Phone: 719-955-1800
  • Fax:
Mailing address:
  • Phone: 719-955-1800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberACD.0002692
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: