Provider Demographics
NPI:1376310003
Name:ROTHROCK, JENNIFER G (CLC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:G
Last Name:ROTHROCK
Suffix:
Gender:F
Credentials:CLC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:GULISH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:IBCLC
Mailing Address - Street 1:8468 HAMDEN RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32244-5466
Mailing Address - Country:US
Mailing Address - Phone:704-576-8748
Mailing Address - Fax:
Practice Address - Street 1:8468 HAMDEN RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32244-5466
Practice Address - Country:US
Practice Address - Phone:704-576-8748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-04
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L-314075174N00000X
351532174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
351532OtherALPP
L-314075OtherIBCLC