Provider Demographics
NPI:1619656006
Name:PHILLIPS, JACQUELINE YEVETTE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:YEVETTE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7490 FRONT BEACH ROAD
Mailing Address - Street 2:UNIT 1127
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32407
Mailing Address - Country:US
Mailing Address - Phone:706-366-9027
Mailing Address - Fax:
Practice Address - Street 1:3800 S OCEAN DR STE 209
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33019-2915
Practice Address - Country:US
Practice Address - Phone:305-466-9988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-13
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9116892363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant