Provider Demographics
NPI:1467716464
Name:PHILLIPS, JESSICA MARIE (LPN)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16118 HUNTMERE AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44110-1545
Mailing Address - Country:US
Mailing Address - Phone:216-322-1852
Mailing Address - Fax:
Practice Address - Street 1:16118 HUNTMERE AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44110-1545
Practice Address - Country:US
Practice Address - Phone:216-322-1852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-25
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN146071164W00000X, 251C00000X
OH146071172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0077930Medicaid