Healthcare Provider Details

I. General information

NPI: 1376082099
Provider Name (Legal Business Name): MRS. JILLIAN PHILLIPS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. JILLIAN GANNON

II. Dates (important events)

Enumeration Date: 02/14/2017
Last Update Date: 04/16/2025
Certification Date: 04/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12823 SOLOLA WAY
TRINITY FL
34655-7246
US

IV. Provider business mailing address

1615 WILMAR AVE
TARPON SPRINGS FL
34689-5776
US

V. Phone/Fax

Practice location:
  • Phone: 727-505-9949
  • Fax:
Mailing address:
  • Phone: 631-495-4224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-25-80647
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: