Healthcare Provider Details

I. General information

NPI: 1619023660
Provider Name (Legal Business Name): JENNIFER ANN PHILLIPS MSW, LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER ANN EDWARDSON MSW, LMSW

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3351 EAGLE RUN DR NE SUITE C
GRAND RAPIDS MI
49525-7053
US

IV. Provider business mailing address

1119 OTTILLIA ST SE
GRAND RAPIDS MI
49507-3762
US

V. Phone/Fax

Practice location:
  • Phone: 616-365-8920
  • Fax:
Mailing address:
  • Phone: 616-791-4795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801081494
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: