Healthcare Provider Details

I. General information

NPI: 1316331408
Provider Name (Legal Business Name): JAYME LEE PHILLIPS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2015
Last Update Date: 11/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7303 N KNOXVILLE AVE
PEORIA IL
61614-2017
US

IV. Provider business mailing address

7303 N KNOXVILLE AVE
PEORIA IL
61614-2017
US

V. Phone/Fax

Practice location:
  • Phone: 309-691-4005
  • Fax: 309-691-6144
Mailing address:
  • Phone: 309-691-4005
  • Fax: 309-691-6144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.006033
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA-616
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: