Provider Demographics
NPI:1649059791
Name:PHILLIPS, KAVENA
Entity type:Individual
Prefix:
First Name:KAVENA
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9077 LEM TURNER RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32208-2268
Mailing Address - Country:US
Mailing Address - Phone:904-651-2034
Mailing Address - Fax:
Practice Address - Street 1:9077 LEM TURNER RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208-2268
Practice Address - Country:US
Practice Address - Phone:904-651-2034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-27
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services