Provider Demographics
NPI:1235521956
Name:RODGERS, PHYLLIS LASHLEY
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:LASHLEY
Last Name:RODGERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3947 BOULEVARD CENTER DR STE 5
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-2833
Mailing Address - Country:US
Mailing Address - Phone:904-470-9965
Mailing Address - Fax:904-375-2768
Practice Address - Street 1:3947 BOULEVARD CENTER DR STE 5
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-2833
Practice Address - Country:US
Practice Address - Phone:904-470-9965
Practice Address - Fax:904-375-2768
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-04
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL126323104A0625X
FL121190364SP0809X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult