Provider Demographics
NPI:1750332714
Name:PHILLIP, JEANNE A (OD)
Entity Type:Individual
Prefix:MS
First Name:JEANNE
Middle Name:A
Last Name:PHILLIP
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 14
Mailing Address - Street 2:
Mailing Address - City:ESSEX JCT
Mailing Address - State:VT
Mailing Address - Zip Code:05453
Mailing Address - Country:US
Mailing Address - Phone:802-878-5509
Mailing Address - Fax:802-879-1350
Practice Address - Street 1:77B PEARL ST
Practice Address - Street 2:
Practice Address - City:ESSEX JCT
Practice Address - State:VT
Practice Address - Zip Code:05452
Practice Address - Country:US
Practice Address - Phone:802-878-5509
Practice Address - Fax:802-879-1350
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0300000338152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN3881Medicaid
VTV07512Medicare UPIN
PHVN3881Medicare PIN