Provider Demographics
NPI:1558595850
Name:PHILLIPS, JASON WENDELL (DC)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:WENDELL
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 1:2738 WINNETKA AVE N
Mailing Address - Street 2:
Mailing Address - City:NEW HOPE
Mailing Address - State:MN
Mailing Address - Zip Code:55427-2850
Mailing Address - Country:US
Mailing Address - Phone:763-546-8622
Mailing Address - Fax:
Practice Address - Street 1:2738 WINNETKA AVE N
Practice Address - Street 2:
Practice Address - City:NEW HOPE
Practice Address - State:MN
Practice Address - Zip Code:55427-2850
Practice Address - Country:US
Practice Address - Phone:763-546-8622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-14
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5226111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor