Basic Information
Provider Information | |||||||||
NPI: | 1588125579 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PHILLIPS | ||||||||
FirstName: | JARED | ||||||||
MiddleName: | DEAN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 86 MDG, UNIT 3215 | ||||||||
Address2: |   | ||||||||
City: | RAMSTEIN AB | ||||||||
State: | GERMANY | ||||||||
PostalCode: | 09094 | ||||||||
CountryCode: | DE | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 307 BOATNER RD | ||||||||
Address2: |   | ||||||||
City: | EGLIN AFB | ||||||||
State: | FL | ||||||||
PostalCode: | 325421302 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8508838600 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/31/2019 | ||||||||
LastUpdateDate: | 09/15/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/15/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MDO.83729 | SC | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 2083A0100X | MDO.83729 | SC | N |   | Allopathic & Osteopathic Physicians | Preventive Medicine | Aerospace Medicine | 390200000X |   |   | Y |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   |
No ID Information.