Provider Demographics
NPI:1801923362
Name:PHILLIPS, JEFFERY ALLEN (BS, CSAC)
Entity type:Individual
Prefix:MR
First Name:JEFFERY
Middle Name:ALLEN
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:BS, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9054
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-9054
Mailing Address - Country:US
Mailing Address - Phone:423-467-3600
Mailing Address - Fax:423-467-3644
Practice Address - Street 1:RR 6 BOX 540
Practice Address - Street 2:
Practice Address - City:GATE CITY
Practice Address - State:VA
Practice Address - Zip Code:24251-9760
Practice Address - Country:US
Practice Address - Phone:276-452-1142
Practice Address - Fax:276-452-1140
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VACSAC 0710101751101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor