Healthcare Provider Details

I. General information

NPI: 1033056536
Provider Name (Legal Business Name): JONATHAN PHILLIPS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2026
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 BOWDEN DR
HAMILTON GA
31811-6907
US

IV. Provider business mailing address

360 BOWDEN DR
HAMILTON GA
31811-6907
US

V. Phone/Fax

Practice location:
  • Phone: 706-405-1952
  • Fax:
Mailing address:
  • Phone: 706-405-1952
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPC007045
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: