Provider Demographics
NPI:1053957746
Name:PHILLIPS, JENNIFER (RSA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:RSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7324 SOUTHWEST FWY STE 1550
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77074-2053
Mailing Address - Country:US
Mailing Address - Phone:713-779-9800
Mailing Address - Fax:713-779-9813
Practice Address - Street 1:6330 BELMONT RD STE 5
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60516-2126
Practice Address - Country:US
Practice Address - Phone:713-779-9800
Practice Address - Fax:713-779-9862
Is Sole Proprietor?:No
Enumeration Date:2019-11-18
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246ZS0410X
IL238000670363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist