Provider Demographics
NPI:1164582433
Name:PHILLIPS, JANE HARAKAL (PHD, LCSW)
Entity Type:Individual
Prefix:DR
First Name:JANE
Middle Name:HARAKAL
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3909 PALUXY HWY
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76048-5538
Mailing Address - Country:US
Mailing Address - Phone:682-225-6990
Mailing Address - Fax:817-860-4082
Practice Address - Street 1:4150 INTERNATIONAL PLZ
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-4892
Practice Address - Country:US
Practice Address - Phone:682-225-6990
Practice Address - Fax:817-860-4082
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-09
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX346631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1752982Medicaid
TX1752982Medicaid
TX611756Medicare ID - Type Unspecified