Provider Demographics
NPI:1417174632
Name:PHILLIPS, JENNIFER (RN)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 KAUFMAN AVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-5145
Mailing Address - Country:US
Mailing Address - Phone:918-456-9524
Mailing Address - Fax:
Practice Address - Street 1:802 KAUFMAN AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-5145
Practice Address - Country:US
Practice Address - Phone:918-456-9524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0028259163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical