Provider Demographics
NPI:1730954546
Name:PHILLIPS, JASON MATTHEW (MH COUNSELOR INTERN)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:MATTHEW
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:MH COUNSELOR INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13004 BERLIN RD
Mailing Address - Street 2:
Mailing Address - City:BERLIN HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44814-9511
Mailing Address - Country:US
Mailing Address - Phone:419-588-2682
Mailing Address - Fax:
Practice Address - Street 1:628 POPLAR ST
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-4065
Practice Address - Country:US
Practice Address - Phone:440-366-1106
Practice Address - Fax:216-334-2882
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-21
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2305059-TRNE101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health