Provider Demographics
NPI:1457314551
Name:WHITE, PHILLIP JON (PT)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:JON
Last Name:WHITE
Suffix:
Gender:M
Credentials:PT
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 556
Mailing Address - Street 2:
Mailing Address - City:YREKA
Mailing Address - State:CA
Mailing Address - Zip Code:96097
Mailing Address - Country:US
Mailing Address - Phone:530-842-5220
Mailing Address - Fax:
Practice Address - Street 1:180 ROSE LN
Practice Address - Street 2:STE 1
Practice Address - City:YREKA
Practice Address - State:CA
Practice Address - Zip Code:96097-3371
Practice Address - Country:US
Practice Address - Phone:530-842-5220
Practice Address - Fax:530-842-5210
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-10
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 22955225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA11543075OtherCAQH PROVIDER NUMBER
CA11543075OtherCAQH PROVIDER NUMBER