Healthcare Provider Details

I. General information

NPI: 1649920257
Provider Name (Legal Business Name): JENNA RUBIE RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2022
Last Update Date: 03/26/2022
Certification Date: 03/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6075 KELTON AVE
LA MESA CA
91942-2728
US

IV. Provider business mailing address

6075 KELTON AVE
LA MESA CA
91942-2728
US

V. Phone/Fax

Practice location:
  • Phone: 425-221-2619
  • Fax:
Mailing address:
  • Phone: 425-221-2619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number794731
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: