Provider Demographics
NPI:1386918803
Name:PHILLIPS, JEANETTE RAE (CMT)
Entity type:Individual
Prefix:MRS
First Name:JEANETTE
Middle Name:RAE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1629 W MAIN ST
Mailing Address - Street 2:SKYLINE PLAZA
Mailing Address - City:ALBERT LEA
Mailing Address - State:MN
Mailing Address - Zip Code:56007-1868
Mailing Address - Country:US
Mailing Address - Phone:507-369-0019
Mailing Address - Fax:507-373-9003
Practice Address - Street 1:1629 W MAIN ST
Practice Address - Street 2:SKYLINE PLAZA
Practice Address - City:ALBERT LEA
Practice Address - State:MN
Practice Address - Zip Code:56007-1868
Practice Address - Country:US
Practice Address - Phone:507-369-0019
Practice Address - Fax:507-373-9003
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-01
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist