Healthcare Provider Details

I. General information

NPI: 1467716464
Provider Name (Legal Business Name): JESSICA MARIE PHILLIPS LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2012
Last Update Date: 12/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16118 HUNTMERE AVE
CLEVELAND OH
44110-1545
US

IV. Provider business mailing address

16118 HUNTMERE AVE
CLEVELAND OH
44110-1545
US

V. Phone/Fax

Practice location:
  • Phone: 216-322-1852
  • Fax:
Mailing address:
  • Phone: 216-322-1852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN146071
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License NumberPN146071
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number146071
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: