Healthcare Provider Details

I. General information

NPI: 1659952810
Provider Name (Legal Business Name): MIKAYLA CELESTE JENSEN RN IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2021
Last Update Date: 04/19/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9511 HOLSBERRY RD STE B8
PENSACOLA FL
32534-1320
US

IV. Provider business mailing address

9511 HOLSBERRY RD STE B8
PENSACOLA FL
32534-1320
US

V. Phone/Fax

Practice location:
  • Phone: 850-324-5393
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-101117
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: