Provider Demographics
NPI:1932657475
Name:PHILLIPS, JAMIE RUSSELL
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:RUSSELL
Last Name:PHILLIPS
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 1:6171 W CHARLESTON BLVD
Mailing Address - Street 2:BLDG 14
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-1126
Mailing Address - Country:US
Mailing Address - Phone:702-486-0464
Mailing Address - Fax:
Practice Address - Street 1:6171 W CHARLESTON BLVD
Practice Address - Street 2:BLDG 14
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-1126
Practice Address - Country:US
Practice Address - Phone:702-486-0464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-13
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor