Provider Demographics
NPI:1790165314
Name:PHILLIPS, JAKE (OTR/L)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:JACOB
Other - Middle Name:
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR/L
Mailing Address - Street 1:2021 CHURCH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-2021
Mailing Address - Country:US
Mailing Address - Phone:615-324-1619
Mailing Address - Fax:615-324-1618
Practice Address - Street 1:2021 CHURCH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-2021
Practice Address - Country:US
Practice Address - Phone:615-324-1619
Practice Address - Fax:615-324-1618
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-09
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5183283X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283X00000XHospitalsRehabilitation Hospital