Provider Demographics
NPI:1376674549
Name:PHILLIPS, JENNIFER (OT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5798 HIGHLAND RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48327-1826
Mailing Address - Country:US
Mailing Address - Phone:248-724-4400
Mailing Address - Fax:248-724-4405
Practice Address - Street 1:5798 HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327-1826
Practice Address - Country:US
Practice Address - Phone:248-724-4400
Practice Address - Fax:248-724-4405
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL994738225X00000X
MI5201007143225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI6211010Medicare PIN
MIN69750040Medicare PIN