Provider Demographics
NPI:1891326559
Name:PHILLIPS, JUSTIN JEROME (MSW)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:JEROME
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23211
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63156-3211
Mailing Address - Country:US
Mailing Address - Phone:313-724-2669
Mailing Address - Fax:
Practice Address - Street 1:4021 LACLEDE AVE # 23211
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-3271
Practice Address - Country:US
Practice Address - Phone:313-724-2669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-31
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health