Provider Demographics
NPI:1053692020
Name:PHILLIPPI, JAY ROBERT (PHD)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:ROBERT
Last Name:PHILLIPPI
Suffix:
Gender:
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 UNIVERSITY DR N STE 140
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-4661
Mailing Address - Country:US
Mailing Address - Phone:701-866-3641
Mailing Address - Fax:
Practice Address - Street 1:112 UNIVERSITY DR N STE 300
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102
Practice Address - Country:US
Practice Address - Phone:701-866-3641
Practice Address - Fax:701-660-1071
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-06
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist