Provider Demographics
NPI:1295414845
Name:JACOBS, KRISTEN (RN, IBCLC)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11207 MALLORY CT
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:IN
Mailing Address - Zip Code:46783-8602
Mailing Address - Country:US
Mailing Address - Phone:260-255-4360
Mailing Address - Fax:
Practice Address - Street 1:11207 MALLORY CT
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:IN
Practice Address - Zip Code:46783-8602
Practice Address - Country:US
Practice Address - Phone:260-615-6883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-12
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28184331A163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation ConsultantGroup - Single Specialty