Provider Demographics
NPI:1922653286
Name:JEWELL, PHILLIP WAYNE
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:WAYNE
Last Name:JEWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21840 HARDING ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-2523
Mailing Address - Country:US
Mailing Address - Phone:313-365-7211
Mailing Address - Fax:313-365-7211
Practice Address - Street 1:16300 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:MI
Practice Address - Zip Code:48203-2882
Practice Address - Country:US
Practice Address - Phone:313-365-7211
Practice Address - Fax:313-365-7211
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist