Provider Demographics
NPI:1740887074
Name:PHILLIPS, JENNIFER RUSSELL (MT-BC, NMT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RUSSELL
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MT-BC, NMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 WOODY LN
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14625-1316
Mailing Address - Country:US
Mailing Address - Phone:585-402-0773
Mailing Address - Fax:
Practice Address - Street 1:50 N PLYMOUTH AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14614-1221
Practice Address - Country:US
Practice Address - Phone:585-454-4596
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225A00000X225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist