Provider Demographics
NPI:1366580227
Name:PHILLIPS, JENNIFER ELIZABETH (PAC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ELIZABETH
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 W MITCHELL ST STE 400
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-2274
Mailing Address - Country:US
Mailing Address - Phone:231-487-2490
Mailing Address - Fax:
Practice Address - Street 1:560 W MITCHELL ST STE 400
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2274
Practice Address - Country:US
Practice Address - Phone:231-330-3246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003293363A00000X
WAPA10004815363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8436487Medicaid
WA4571LEOtherBLUE SHIELD
MI1366580227Medicaid
WAUS7122654OtherAETNA SPECIALIST PIN
WA0039572OtherLABOR AND INDUSTRIES#
WA4571LEOtherBLUE SHIELD