Provider Demographics
NPI:1073912895
Name:PHILLIPS, JACQUELINE (MS, ATC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 E 2ND ST FL 4
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-2200
Mailing Address - Country:US
Mailing Address - Phone:218-249-6526
Mailing Address - Fax:218-249-6370
Practice Address - Street 1:1012 E 2ND ST FL 4
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-2200
Practice Address - Country:US
Practice Address - Phone:218-249-6526
Practice Address - Fax:218-249-6370
Is Sole Proprietor?:No
Enumeration Date:2014-08-18
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN22842255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer