Healthcare Provider Details

I. General information

NPI: 1669763702
Provider Name (Legal Business Name): JACQUELINE M PHILLIPS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACQUELINE M BORS

II. Dates (important events)

Enumeration Date: 04/24/2011
Last Update Date: 09/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2979 WOODSIDE ROAD
WOODSIDE CA
94062
US

IV. Provider business mailing address

2979 WOODSIDE RD
WOODSIDE CA
94062-2443
US

V. Phone/Fax

Practice location:
  • Phone: 650-851-4747
  • Fax: 650-851-4343
Mailing address:
  • Phone: 650-851-4747
  • Fax: 650-851-4343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA125544
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: