Provider Demographics
NPI:1164292439
Name:JACKSON, BRIANNA SARAH (IBCLC)
Entity Type:Individual
Prefix:MRS
First Name:BRIANNA
Middle Name:SARAH
Last Name:JACKSON
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1233 ALLENGROVE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19124-2903
Mailing Address - Country:US
Mailing Address - Phone:434-444-7126
Mailing Address - Fax:
Practice Address - Street 1:1355 OLD YORK RD
Practice Address - Street 2:
Practice Address - City:ABINGTON
Practice Address - State:PA
Practice Address - Zip Code:19001-3413
Practice Address - Country:US
Practice Address - Phone:215-886-2433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAL-312748163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant