Healthcare Provider Details

I. General information

NPI: 1538563887
Provider Name (Legal Business Name): JENNIFER GENTRY MA, IBCLC, RLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2014
Last Update Date: 01/07/2021
Certification Date: 01/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S LAKE ST STE B
MUNDELEIN IL
60060-4255
US

IV. Provider business mailing address

1500 S LAKE ST STE B
MUNDELEIN IL
60060-4255
US

V. Phone/Fax

Practice location:
  • Phone: 847-837-4091
  • Fax:
Mailing address:
  • Phone: 847-837-4091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: