Provider Demographics
NPI:1528735875
Name:PHILLIPS, JESSICA LAURA (FNP)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LAURA
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1081 FENTON PARK DR
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-7614
Mailing Address - Country:US
Mailing Address - Phone:573-883-6434
Mailing Address - Fax:
Practice Address - Street 1:1081 FENTON PARK DR
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-7614
Practice Address - Country:US
Practice Address - Phone:573-883-6434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-25
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209023707363LF0000X
MO2021006345363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily