Provider Demographics
NPI:1174130462
Name:PHILLIPS, JESSICA LEMOINE (APRN)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEMOINE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1985 HIGHLAND PARK CT
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-4758
Mailing Address - Country:US
Mailing Address - Phone:903-530-5455
Mailing Address - Fax:
Practice Address - Street 1:630 S FLEISHEL AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2041
Practice Address - Country:US
Practice Address - Phone:903-606-5560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP145382363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP145382OtherTEXAS BOARD OF NURSING
TX1I1449OtherMEDICARE