Provider Demographics
NPI:1922754225
Name:ALLEN, PHILLIP JASON (LAT)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:JASON
Last Name:ALLEN
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:432 MILLARD ST
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-2024
Mailing Address - Country:US
Mailing Address - Phone:512-422-3489
Mailing Address - Fax:
Practice Address - Street 1:1320 COLLABORATIVE WAY
Practice Address - Street 2:
Practice Address - City:LEANDER
Practice Address - State:TX
Practice Address - Zip Code:78641-9081
Practice Address - Country:US
Practice Address - Phone:125-701-4805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-24
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT22502255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer