Provider Demographics
NPI:1669739702
Name:PHILLIPS, JASON RYAN (LP, CP CFTS)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:RYAN
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:LP, CP CFTS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7619 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79423-2125
Mailing Address - Country:US
Mailing Address - Phone:806-799-1518
Mailing Address - Fax:806-799-5462
Practice Address - Street 1:7619 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79423-2125
Practice Address - Country:US
Practice Address - Phone:806-799-1518
Practice Address - Fax:806-799-5462
Is Sole Proprietor?:No
Enumeration Date:2012-04-13
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX252224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145567702Medicaid
TX145567702Medicaid