Provider Demographics
NPI:1518612084
Name:DEAN, JENNIFER (IBCLC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DEAN
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 1:980 S MONTGOMERY ST
Mailing Address - Street 2:
Mailing Address - City:GILMER
Mailing Address - State:TX
Mailing Address - Zip Code:75644-8765
Mailing Address - Country:US
Mailing Address - Phone:903-790-1285
Mailing Address - Fax:903-843-5533
Practice Address - Street 1:980 S MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:GILMER
Practice Address - State:TX
Practice Address - Zip Code:75644-8765
Practice Address - Country:US
Practice Address - Phone:903-790-1285
Practice Address - Fax:903-843-5533
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-14
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL-18200174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN