Provider Demographics
NPI:1316931553
Name:JEANMENNE, PHILLIP R (BS, DC)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:R
Last Name:JEANMENNE
Suffix:
Gender:M
Credentials:BS, DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1776 S QUEEN ST # 101-B
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17403-4628
Mailing Address - Country:US
Mailing Address - Phone:717-848-5400
Mailing Address - Fax:717-848-1071
Practice Address - Street 1:1776 S QUEEN ST # 101-B
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-4628
Practice Address - Country:US
Practice Address - Phone:717-848-5400
Practice Address - Fax:717-848-1071
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-02
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC-005036-L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014751980001Medicaid
PA0014751980001Medicaid
PAU40283Medicare UPIN
PAJE764815Medicare ID - Type Unspecified