Provider Demographics
NPI:1134474398
Name:PHILLIPS, JOLENE ROSE
Entity type:Individual
Prefix:MRS
First Name:JOLENE
Middle Name:ROSE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JOLENE
Other - Middle Name:ROSE
Other - Last Name:COMO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:328 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01550-3794
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:328 MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTHBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01550-3794
Practice Address - Country:US
Practice Address - Phone:508-765-9101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-13
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health