Provider Demographics
NPI:1881181824
Name:WILLIS, JESSICA (IBCLC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:JESS
Other - Middle Name:
Other - Last Name:WILLIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:IBCLC
Mailing Address - Street 1:10852 WINGATE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-4575
Mailing Address - Country:US
Mailing Address - Phone:904-323-1418
Mailing Address - Fax:
Practice Address - Street 1:10852 WINGATE RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-4575
Practice Address - Country:US
Practice Address - Phone:904-323-1418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-16
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN