Provider Demographics
NPI:1275870172
Name:FOSTER, JENNIFER MICHELLE (MA, CD, IBCLC, RLC)
Entity Type:Individual
Prefix:PROF
First Name:JENNIFER
Middle Name:MICHELLE
Last Name:FOSTER
Suffix:
Gender:F
Credentials:MA, CD, IBCLC, RLC
Other - Prefix:PROF
Other - First Name:JENN
Other - Middle Name:MICHELLE
Other - Last Name:FOSTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CD, IBCLC, RLC
Mailing Address - Street 1:213 RUSSELL CT
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115-2918
Mailing Address - Country:US
Mailing Address - Phone:470-533-9119
Mailing Address - Fax:
Practice Address - Street 1:213 RUSSELL CT
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-2918
Practice Address - Country:US
Practice Address - Phone:470-533-9119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-11
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
No332900000XSuppliersNon-Pharmacy Dispensing Site
No372500000XNursing Service Related ProvidersChore Provider
No374J00000XNursing Service Related ProvidersDoula
No374T00000XNursing Service Related ProvidersReligious Nonmedical Nursing Personnel
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLA536433835890OtherFLORIDA DRIVER'S LICENSE
FL26-3017550Other1275870172