Provider Demographics
NPI:1609826171
Name:PHILLIPS, JACQUELYN RENEE (APNP)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:RENEE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:MISS
Other - First Name:JACQUELYN
Other - Middle Name:RENEE
Other - Last Name:MUELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:744 S WEBSTER AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3505
Practice Address - Country:US
Practice Address - Phone:920-433-3640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1948-023363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42881800Medicaid
WI000053Medicare Oscar/Certification
WIQ65366Medicare UPIN
WI42881800Medicaid
WIK400263489Medicare Oscar/Certification
WI000030Medicare Oscar/Certification
WI000073Medicare Oscar/Certification
WI000027Medicare Oscar/Certification
WI000041Medicare Oscar/Certification