Provider Demographics
NPI:1821297078
Name:PHILLIPS, JODI LYNN (LPN)
Entity Type:Individual
Prefix:MRS
First Name:JODI
Middle Name:LYNN
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:765 JORDANVILLE ROAD
Mailing Address - Street 2:
Mailing Address - City:ILION
Mailing Address - State:NY
Mailing Address - Zip Code:13357-3412
Mailing Address - Country:US
Mailing Address - Phone:315-822-3356
Mailing Address - Fax:315-822-3167
Practice Address - Street 1:765 JORDANVILLE ROAD
Practice Address - Street 2:
Practice Address - City:ILION
Practice Address - State:NY
Practice Address - Zip Code:13357-3412
Practice Address - Country:US
Practice Address - Phone:315-822-3356
Practice Address - Fax:315-822-3167
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-17
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY273174-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02478857Medicaid