Provider Demographics
NPI:1639305527
Name:PHILLIPS, JENNIFER (LICSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:HUGHES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:208 FLYNN AVE
Mailing Address - Street 2:SUITE 3J
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-5429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1025 AIRPORT DR
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-6013
Practice Address - Country:US
Practice Address - Phone:802-488-7711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-05
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT08900012211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1016791Medicaid
VT001057301Medicare PIN