Provider Demographics
NPI:1992842108
Name:PHILIPS, JESSE (MFT)
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:
Last Name:PHILIPS
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:637 MILWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-3862
Mailing Address - Country:US
Mailing Address - Phone:310-301-0484
Mailing Address - Fax:
Practice Address - Street 1:637 MILWOOD AVE
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-3862
Practice Address - Country:US
Practice Address - Phone:310-301-0484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAM14215106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist