Healthcare Provider Details

I. General information

NPI: 1376310003
Provider Name (Legal Business Name): JENNIFER G ROTHROCK CLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER GULISH IBCLC

II. Dates (important events)

Enumeration Date: 12/04/2023
Last Update Date: 03/13/2024
Certification Date: 03/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8468 HAMDEN RD
JACKSONVILLE FL
32244-5466
US

IV. Provider business mailing address

8468 HAMDEN RD
JACKSONVILLE FL
32244-5466
US

V. Phone/Fax

Practice location:
  • Phone: 704-576-8748
  • Fax:
Mailing address:
  • Phone: 704-576-8748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-314075
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number351532
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: