MEDICARE: JENELLE PHILLIPS LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	LCSW22149	CA

General Provider Information

NPI Number	:	1063973030
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENELLE PHILLIPS LCSW

Provider Business Mailing Address
First Line	:	120 AMANDA LN
Second Line	:
City	:	LOS GATOS
State	:	CA
Zip	:	95032-4713
Country	:	US
Telephone Number	:	408-896-0736
Fax Number	:

Provider Business Practice Location Address
First Line	:	718 UNIVERSITY AVE STE 110
Second Line	:
City	:	LOS GATOS
State	:	CA
Zip	:	95032-7608
Country	:	US
Telephone Number	:	408-896-0736
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/30/2019
Last Update Date	:	03/30/2019

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