Provider Demographics
NPI:1982914487
Name:JAH, CASSAUNDRA RENEA (CPM, IBCLC)
Entity Type:Individual
Prefix:MS
First Name:CASSAUNDRA
Middle Name:RENEA
Last Name:JAH
Suffix:
Gender:F
Credentials:CPM, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 PINON TRL
Mailing Address - Street 2:
Mailing Address - City:CEDAR CREST
Mailing Address - State:NM
Mailing Address - Zip Code:87008-9457
Mailing Address - Country:US
Mailing Address - Phone:505-407-4378
Mailing Address - Fax:
Practice Address - Street 1:176 PINON TRL
Practice Address - Street 2:
Practice Address - City:CEDAR CREST
Practice Address - State:NM
Practice Address - Zip Code:87008-9457
Practice Address - Country:US
Practice Address - Phone:505-407-4378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-18
Last Update Date:2012-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM10076R176B00000X
NM11065708163WL0100X
374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No374J00000XNursing Service Related ProvidersDoula
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM31781349Medicaid