Provider Demographics
NPI:1770670689
Name:PHILLIPS, JACQUELINE (PHD)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:PHILLIPS-SABOL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:120 E 2ND ST
Mailing Address - Street 2:FL 3
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16507-1578
Mailing Address - Country:US
Mailing Address - Phone:713-500-3500
Mailing Address - Fax:
Practice Address - Street 1:6410 FANNIN ST STE 1014
Practice Address - Street 2:ATTN: DIRECTOR OF NEUROPSYCHOLOGY
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-5301
Practice Address - Country:US
Practice Address - Phone:713-486-0503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS017778103G00000X
IL071007399103G00000X
TX34043103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0533210001OtherDMERC
TX2030728-01Medicaid
IL0533210001OtherDMERC