Provider Demographics
NPI:1174674089
Name:PHILLIPS, JEFFREY (DC)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1129
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-0363
Mailing Address - Country:US
Mailing Address - Phone:909-792-4434
Mailing Address - Fax:
Practice Address - Street 1:620 ALABAMA ST
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-8059
Practice Address - Country:US
Practice Address - Phone:909-792-4434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0221220111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0221220Medicaid