Healthcare Provider Details

I. General information

NPI: 1689442402
Provider Name (Legal Business Name): JACQUELINE SEVERSON RN, BSN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2023
Last Update Date: 12/12/2023
Certification Date: 12/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14040 N CAVE CREEK RD
PHOENIX AZ
85022-6117
US

IV. Provider business mailing address

3002 N 70TH ST UNIT 209
SCOTTSDALE AZ
85251-6339
US

V. Phone/Fax

Practice location:
  • Phone: 602-299-7475
  • Fax: 623-806-8655
Mailing address:
  • Phone: 602-299-7475
  • Fax: 623-806-8655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-87868
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: