Provider Demographics
NPI:1962850677
Name:FORESTER, JENNA (RN BSN IBCLC)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:FORESTER
Suffix:
Gender:F
Credentials:RN BSN IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15736 VISTA DR
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:VA
Mailing Address - Zip Code:22025-1812
Mailing Address - Country:US
Mailing Address - Phone:540-320-0118
Mailing Address - Fax:
Practice Address - Street 1:15736 VISTA DR
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:VA
Practice Address - Zip Code:22025-1812
Practice Address - Country:US
Practice Address - Phone:540-320-0118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-03
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001218672163W00000X
VAL-46303174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No174400000XOther Service ProvidersSpecialist