Provider Demographics
NPI:1730908088
Name:PHILLIPS, JOHN R
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:R
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 1:1200 S CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46802-3504
Mailing Address - Country:US
Mailing Address - Phone:260-467-2850
Mailing Address - Fax:
Practice Address - Street 1:1200 BARR ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-3502
Practice Address - Country:US
Practice Address - Phone:260-467-1010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-04
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10104377103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool