Provider Demographics
NPI:1932821766
Name:MARLLES, JESSICA (CLC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MARLLES
Suffix:
Gender:F
Credentials:CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 MULBERRY LOOP NE
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58703-0577
Mailing Address - Country:US
Mailing Address - Phone:859-447-1205
Mailing Address - Fax:
Practice Address - Street 1:74 MULBERRY LOOP NE
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58703-0577
Practice Address - Country:US
Practice Address - Phone:859-447-1205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT329530174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN