Provider Demographics
NPI:1457587388
Name:PHELPS, JILLIAN MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:JILLIAN
Middle Name:MARIE
Last Name:PHELPS
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 1:2610 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-1735
Mailing Address - Country:US
Mailing Address - Phone:815-397-2020
Mailing Address - Fax:815-397-8694
Practice Address - Street 1:2610 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-1735
Practice Address - Country:US
Practice Address - Phone:815-397-2020
Practice Address - Fax:815-397-8694
Is Sole Proprietor?:No
Enumeration Date:2009-06-05
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL46010007152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist