Healthcare Provider Details

I. General information

NPI: 1750332714
Provider Name (Legal Business Name): JEANNE A PHILLIP OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 02/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77B PEARL ST
ESSEX JCT VT
05452
US

IV. Provider business mailing address

PO BOX 14
ESSEX JCT VT
05453
US

V. Phone/Fax

Practice location:
  • Phone: 802-878-5509
  • Fax: 802-879-1350
Mailing address:
  • Phone: 802-878-5509
  • Fax: 802-879-1350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0300000338
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: