Healthcare Provider Details

I. General information

NPI: 1831076637
Provider Name (Legal Business Name): JESSICA POLING IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2025
Last Update Date: 08/21/2025
Certification Date: 08/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 E LAUREL AVE
HAVANA IL
62644-6973
US

IV. Provider business mailing address

1002 E LAUREL AVE
HAVANA IL
62644-6973
US

V. Phone/Fax

Practice location:
  • Phone: 309-210-0110
  • Fax: 309-543-2063
Mailing address:
  • Phone: 309-210-0110
  • Fax: 309-543-2063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-318921
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: