Healthcare Provider Details

I. General information

NPI: 1073912895
Provider Name (Legal Business Name): JACQUELINE PHILLIPS MS, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2014
Last Update Date: 11/28/2025
Certification Date: 11/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2770 E BELTLINE AVE NE
GRAND RAPIDS MI
49525-8614
US

IV. Provider business mailing address

2770 E BELTLINE AVE NE
GRAND RAPIDS MI
49525-8614
US

V. Phone/Fax

Practice location:
  • Phone: 616-267-8860
  • Fax: 616-267-8442
Mailing address:
  • Phone: 616-267-8860
  • Fax: 616-267-8442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601002859
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: