Provider Demographics
NPI:1114103751
Name:PHILLIPS, JERRY FRANKLIN (LMHC)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:FRANKLIN
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3420 HWY 27/441
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:34731-4474
Mailing Address - Country:US
Mailing Address - Phone:352-435-4631
Mailing Address - Fax:352-435-4632
Practice Address - Street 1:3420 HWY 27/441
Practice Address - Street 2:
Practice Address - City:FRUITLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:34731-4474
Practice Address - Country:US
Practice Address - Phone:352-435-4631
Practice Address - Fax:352-435-4632
Is Sole Proprietor?:No
Enumeration Date:2008-01-14
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLM-4358101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLM-4358OtherLMHC