Provider Demographics
NPI:1407961345
Name:PHILLIPS, JENNIFER (FNP, BC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:FNP, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3753 MESQUITE DR
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45440-3493
Mailing Address - Country:US
Mailing Address - Phone:937-912-5554
Mailing Address - Fax:
Practice Address - Street 1:4244 INDIAN RIPPLE RD
Practice Address - Street 2:STE 300
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45440-3279
Practice Address - Country:US
Practice Address - Phone:937-429-3366
Practice Address - Fax:937-429-0956
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP08036363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner