Healthcare Provider Details

I. General information

NPI: 1477837789
Provider Name (Legal Business Name): JEFFREY P PHILLIPS M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2011
Last Update Date: 07/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 W 15TH
PLEASANTON KS
66075-4095
US

IV. Provider business mailing address

PO BOX 807 304 N JEFFERSON AVE
IOL KS
66749-2324
US

V. Phone/Fax

Practice location:
  • Phone: 912-352-8214
  • Fax: 913-352-8236
Mailing address:
  • Phone: 620-365-8641
  • Fax: 620-365-8642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1427
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: