Provider Demographics
NPI:1093440992
Name:FASSE, JOLENE ANN (RN, IBCLC)
Entity Type:Individual
Prefix:MRS
First Name:JOLENE
Middle Name:ANN
Last Name:FASSE
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20104 RIDGEFIELD LOOP
Mailing Address - Street 2:
Mailing Address - City:SPEARFISH
Mailing Address - State:SD
Mailing Address - Zip Code:57783-3301
Mailing Address - Country:US
Mailing Address - Phone:605-645-1711
Mailing Address - Fax:
Practice Address - Street 1:1440 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SPEARFISH
Practice Address - State:SD
Practice Address - Zip Code:57783-1505
Practice Address - Country:US
Practice Address - Phone:605-644-4048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-24
Last Update Date:2022-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR029884163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant