Provider Demographics
NPI:1831880855
Name:PHILLIPS, JENNIFER (LDO)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 SHALLOWFORD RD NW
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30504-4152
Mailing Address - Country:US
Mailing Address - Phone:770-503-7313
Mailing Address - Fax:770-503-7321
Practice Address - Street 1:400 SHALLOWFORD RD NW
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30504-4152
Practice Address - Country:US
Practice Address - Phone:770-503-7313
Practice Address - Fax:770-503-7321
Is Sole Proprietor?:No
Enumeration Date:2023-05-19
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO002125156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician