Provider Demographics
NPI:1316985823
Name:DEPHILLIPS, JENNIFER RENEE (PA-C)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:RENEE
Last Name:DEPHILLIPS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:RENEE
Other - Last Name:SPEER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:264 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-2551
Mailing Address - Country:US
Mailing Address - Phone:603-224-3368
Mailing Address - Fax:603-224-7815
Practice Address - Street 1:264 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-2551
Practice Address - Country:US
Practice Address - Phone:603-224-3368
Practice Address - Fax:603-224-7815
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1762363A00000X
AZ3332363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ977598Medicaid
AZZ107449Medicare PIN
AZ977598Medicaid