Healthcare Provider Details

I. General information

NPI: 1962099804
Provider Name (Legal Business Name): JENICA MARISSA WILLIS LM, CPM, LVN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2020
Last Update Date: 03/15/2025
Certification Date: 03/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 17TH STREET
BAKERSFIELD CA
93301-6172
US

IV. Provider business mailing address

1031 17TH STREET
BAKERSFIELD CA
93301
US

V. Phone/Fax

Practice location:
  • Phone: 661-234-9894
  • Fax: 661-360-6243
Mailing address:
  • Phone: 661-234-9894
  • Fax: 661-360-6243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number286953
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-302379
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberLM764
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: