Provider Demographics
NPI:1851690135
Name:PHILLIPS, JODIE MARIE (BSW)
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:MARIE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:MI
Mailing Address - Zip Code:49304-7984
Mailing Address - Country:US
Mailing Address - Phone:231-745-3116
Mailing Address - Fax:231-745-3136
Practice Address - Street 1:1615 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:MI
Practice Address - Zip Code:49304-7984
Practice Address - Country:US
Practice Address - Phone:231-745-3116
Practice Address - Fax:231-745-3136
Is Sole Proprietor?:No
Enumeration Date:2011-03-25
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802085547104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker