Provider Demographics
NPI:1720174360
Name:PHILLIPS, JENNY LYNN (PA)
Entity Type:Individual
Prefix:MISS
First Name:JENNY
Middle Name:LYNN
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 CARTER STREET SUITE 102
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37402
Mailing Address - Country:US
Mailing Address - Phone:423-933-3397
Mailing Address - Fax:423-933-3398
Practice Address - Street 1:1401 CARTER STREET SUITE 102
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37402
Practice Address - Country:US
Practice Address - Phone:423-933-3397
Practice Address - Fax:423-933-3398
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA1299363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0140208OtherUNITED HEALTHCARE
TN3663990Medicaid
TN970027904OtherRAILROAD MEDICARE
TN2000307OtherBCBS OF TN
TNTN0101OtherJOHN DEERE
TNFP62706OtherWORKERS COMP
TNTN0101OtherJOHN DEERE
TN970027904OtherRAILROAD MEDICARE
TNFP62706OtherWORKERS COMP
TNFP62706OtherWORKERS COMP