Provider Demographics
NPI:1619023660
Name:PHILLIPS, JENNIFER ANN (MSW, LMSW)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ANN
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MSW, LMSW
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:ANN
Other - Last Name:EDWARDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, LMSW
Mailing Address - Street 1:1119 OTTILLIA ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49507-3762
Mailing Address - Country:US
Mailing Address - Phone:616-791-4795
Mailing Address - Fax:
Practice Address - Street 1:3351 EAGLE RUN DR NE
Practice Address - Street 2:SUITE C
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-7053
Practice Address - Country:US
Practice Address - Phone:616-365-8920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010814941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical