Provider Demographics
NPI:1851703029
Name:GWYN, JENNIFER (BS, IBCLC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:GWYN
Suffix:
Gender:F
Credentials:BS, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6918 CHINOOK DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78736-1802
Mailing Address - Country:US
Mailing Address - Phone:512-217-3834
Mailing Address - Fax:
Practice Address - Street 1:6918 CHINOOK DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78736-1802
Practice Address - Country:US
Practice Address - Phone:512-217-3834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-22
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX47506174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN