Provider Demographics
NPI:1518217033
Name:PHIPPS, JESSICA ROSE (LCSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ROSE
Last Name:PHIPPS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 S MARSHALL ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-5808
Mailing Address - Country:US
Mailing Address - Phone:336-722-7266
Mailing Address - Fax:336-201-0538
Practice Address - Street 1:2235 LEWISVILLE CLEMMONS RD STE A
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-9342
Practice Address - Country:US
Practice Address - Phone:336-722-7266
Practice Address - Fax:480-428-0475
Is Sole Proprietor?:No
Enumeration Date:2012-09-12
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0091591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1518217033Medicare NSC