Provider Demographics
NPI:1700512423
Name:PHILLIPS, DERRICK JESSE
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:JESSE
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 1:1616 RIDGE HAVEN DR APT 510
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76011-9097
Mailing Address - Country:US
Mailing Address - Phone:817-658-8367
Mailing Address - Fax:
Practice Address - Street 1:1616 RIDGE HAVEN DR APT 510
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76011-9097
Practice Address - Country:US
Practice Address - Phone:817-658-8367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-26
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1315697225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist