Provider Demographics
NPI:1477567675
Name:PHILLIPS, JENNIFER RAE (MS, CCC-SLP/L)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:RAE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MS, CCC-SLP/L
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:RAE
Other - Last Name:GREENE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP/L
Mailing Address - Street 1:774 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-2609
Mailing Address - Country:US
Mailing Address - Phone:716-338-0668
Mailing Address - Fax:866-694-4979
Practice Address - Street 1:774 FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-2609
Practice Address - Country:US
Practice Address - Phone:716-338-0668
Practice Address - Fax:866-694-4979
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY02324358235Z00000X
NY013565-1235Z00000X
251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02324358Medicaid
NYJ400109168Medicare Oscar/Certification