Provider Demographics
NPI:1033447545
Name:PHILLIPS, JILLIAN MIRANDA (LPC)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:MIRANDA
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6549 TOWN CENTER DR STE A
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-4824
Mailing Address - Country:US
Mailing Address - Phone:248-620-6400
Mailing Address - Fax:
Practice Address - Street 1:32961 MIDDLEBELT RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-1729
Practice Address - Country:US
Practice Address - Phone:248-855-1540
Practice Address - Fax:248-855-2481
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-20
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401015006101YP2500X
MI6803086138104100000X
MI6401222998101YP2500X
MIRBT-21-6721-278909106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician