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NPI Code Detail

MEDICARE: MR. PHILLIP JASON SOUTHERS RBT

MEDICARE: MR. PHILLIP JASON SOUTHERS RBT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1106S00000XBehavior TechnicianRBT-21-174090AL

General Provider Information

NPI Number : 1639840754
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. PHILLIP JASON SOUTHERS RBT
Provider Business Mailing Address
First Line : 415 N RICHARD JACKSON BLVD
Second Line :
City : PANAMA CITY
State : FL
Zip : 32407-3664
Country : US
Telephone Number : 850-866-0441
Fax Number : 850-254-0827
Provider Business Practice Location Address
First Line : 6125 UNIVERSITY DR NW STE B22
Second Line :
City : HUNTSVILLE
State : AL
Zip : 35806-1765
Country : US
Telephone Number : 256-692-9262
Fax Number : 888-392-7185
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/28/2021
Last Update Date : 09/28/2021

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