Provider Demographics
NPI:1306140017
Name:PHILLIPS, JACOB EUGENE (PA-C)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:EUGENE
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 ALEXANDRIA BLVD
Mailing Address - Street 2:STE. 1030
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-3300
Mailing Address - Country:US
Mailing Address - Phone:321-765-4373
Mailing Address - Fax:407-542-0666
Practice Address - Street 1:40 ALEXANDRIA BLVD
Practice Address - Street 2:STE. 1030
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-3300
Practice Address - Country:US
Practice Address - Phone:321-765-4373
Practice Address - Fax:407-542-0666
Is Sole Proprietor?:No
Enumeration Date:2011-01-10
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105852363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLEV633WMedicare UPIN