Provider Demographics
NPI:1639757081
Name:BRASSART, JENNA ASHLEY (IBCLC)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:ASHLEY
Last Name:BRASSART
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 1:1368 CLARKS BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:MYRTLE CREEK
Mailing Address - State:OR
Mailing Address - Zip Code:97457-9751
Mailing Address - Country:US
Mailing Address - Phone:541-680-3081
Mailing Address - Fax:
Practice Address - Street 1:2564 NW EDENBOWER BLVD STE 134
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-8854
Practice Address - Country:US
Practice Address - Phone:541-492-2350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-29
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLC-10206731174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN