Provider Demographics
NPI:1235939521
Name:PHILLIPS, JASON RICHARD (AMFT)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:RICHARD
Last Name:PHILLIPS
Suffix:
Gender:
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5214 VINCENT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90041-1401
Mailing Address - Country:US
Mailing Address - Phone:323-804-4412
Mailing Address - Fax:
Practice Address - Street 1:5214 VINCENT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90041-1401
Practice Address - Country:US
Practice Address - Phone:323-804-4412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-15
Last Update Date:2025-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT139508106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist