Provider Demographics
NPI:1689911539
Name:PHILLIPS, JASON LAMAR (LLMSW)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:LAMAR
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4925 PACKARD ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1521
Mailing Address - Country:US
Mailing Address - Phone:734-971-9781
Mailing Address - Fax:734-971-2730
Practice Address - Street 1:4925 PACKARD ST
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-1521
Practice Address - Country:US
Practice Address - Phone:734-971-9781
Practice Address - Fax:734-971-2730
Is Sole Proprietor?:No
Enumeration Date:2013-01-12
Last Update Date:2013-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010929341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical