Provider Demographics
NPI:1518257716
Name:MCCULLOCH, JEANETTE (IBCLC, RLC)
Entity type:Individual
Prefix:
First Name:JEANETTE
Middle Name:
Last Name:MCCULLOCH
Suffix:
Gender:F
Credentials:IBCLC, RLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 1ST ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-3405
Mailing Address - Country:US
Mailing Address - Phone:607-330-2741
Mailing Address - Fax:
Practice Address - Street 1:115 1ST ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-3405
Practice Address - Country:US
Practice Address - Phone:607-330-2741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-09
Last Update Date:2011-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
11093528174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN