Basic Information
| Provider Information | |||||||||
| NPI: | 1376528497 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHILLPOTTS | ||||||||
| FirstName: | JEAN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 S BALLENGER HWY | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485323638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103421000 | ||||||||
| FaxNumber: | 8103421590 | ||||||||
| Practice Location | |||||||||
| Address1: | 4015 DAVISON RD | ||||||||
| Address2: | |||||||||
| City: | BURTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485091401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8107151875 | ||||||||
| FaxNumber: | 8107428911 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 4704114147 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 1010141 | 01 | MI | HEALTH ADVANTAGE NETWORK | OTHER | 4622831 | 05 | MI | MEDICAID | 4208702600 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 4622798 | 05 | MI | MEDICAID | 1010141 | 01 | MI | MCLAREN HEALTH PLAN | OTHER |