Provider Demographics
NPI:1134516925
Name:PHILLIPS, JARRAD MARSHALL (ATC)
Entity Type:Individual
Prefix:
First Name:JARRAD
Middle Name:MARSHALL
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9331 VIENTO FUERTE WAY
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-6820
Mailing Address - Country:US
Mailing Address - Phone:619-820-0872
Mailing Address - Fax:
Practice Address - Street 1:9331 VIENTO FUERTE WAY
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-6820
Practice Address - Country:US
Practice Address - Phone:619-820-0872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-20
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0204021892255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer