Provider Demographics
NPI:1134871965
Name:PHILLIPS-JACKSON, LONNIE J
Entity type:Individual
Prefix:
First Name:LONNIE
Middle Name:J
Last Name:PHILLIPS-JACKSON
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 1:1221 E APACHE BLVD APT 3060
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85281-1185
Mailing Address - Country:US
Mailing Address - Phone:775-354-3675
Mailing Address - Fax:
Practice Address - Street 1:1221 E APACHE BLVD APT 3060
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-1185
Practice Address - Country:US
Practice Address - Phone:775-354-3675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-23
Last Update Date:2022-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000000000OtherNONW