Provider Demographics
NPI:1093435703
Name:KOMOROSKI, JACQUELINE (RN, IBCLC)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:
Last Name:KOMOROSKI
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:MS
Other - First Name:JACKIE
Other - Middle Name:
Other - Last Name:KOMOROSKI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN, IBCLC
Mailing Address - Street 1:6480 PINE RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-9265
Mailing Address - Country:US
Mailing Address - Phone:404-783-5809
Mailing Address - Fax:
Practice Address - Street 1:6480 PINE RIDGE CIR
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-9265
Practice Address - Country:US
Practice Address - Phone:404-783-5809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-01
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAL-130081163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant