Healthcare Provider Details

I. General information

NPI: 1821027756
Provider Name (Legal Business Name): JACQUELINE PHILLIPS DPM INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 12/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5575 CONNER ST SUITE 203
DETROIT MI
48213-6400
US

IV. Provider business mailing address

5575 CONNER ST SUITE 203
DETROIT MI
48213-6400
US

V. Phone/Fax

Practice location:
  • Phone: 313-345-4449
  • Fax:
Mailing address:
  • Phone: 313-345-4449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number5901001422
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number5901001422
License Number StateMI

VIII. Authorized Official

Name: DR. JACQUELINE PHILLIPS
Title or Position: PODIATRIST
Credential: DPM
Phone: 313-345-4449