Provider Demographics
NPI:1053861344
Name:PHILLIPS, JACQUELINE JOY (MS ED)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:JOY
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MS ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:561 ROUTE 9W
Mailing Address - Street 2:
Mailing Address - City:PIERMONT
Mailing Address - State:NY
Mailing Address - Zip Code:10968-1116
Mailing Address - Country:US
Mailing Address - Phone:845-680-7580
Mailing Address - Fax:
Practice Address - Street 1:561 ROUTE 9W
Practice Address - Street 2:
Practice Address - City:PIERMONT
Practice Address - State:NY
Practice Address - Zip Code:10968-1116
Practice Address - Country:US
Practice Address - Phone:845-680-7580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-11
Last Update Date:2017-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY859725174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist