Provider Demographics
NPI:1609123132
Name:PHILLIPS, JONNA BETH (LMFT)
Entity type:Individual
Prefix:
First Name:JONNA
Middle Name:BETH
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8120 MOORSBRIDGE RD STE 203
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-7414
Mailing Address - Country:US
Mailing Address - Phone:612-499-3424
Mailing Address - Fax:
Practice Address - Street 1:8120 MOORSBRIDGE RD STE 203
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-7414
Practice Address - Country:US
Practice Address - Phone:269-389-9643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-15
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2220106H00000X
MI4101006773106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist