Basic Information
| Provider Information | |||||||||
| NPI: | 1104939107 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHILLIPS | ||||||||
| FirstName: | JANNEL | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PH.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 36985 VARGO ST | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481522715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484704601 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 FORD PLACE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138762526 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 03/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | 6301015369 | MI | N | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103G00000X | 6208 | OH | N | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103G00000X | 1432 | KY | N | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103TC0700X | 6301015369 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.