Healthcare Provider Details

I. General information

NPI: 1043943533
Provider Name (Legal Business Name): ELIZABETH JETT RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2022
Last Update Date: 07/02/2022
Certification Date: 05/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3618 LEXINGTON RD
LOUISVILLE KY
40207-2950
US

IV. Provider business mailing address

3618 LEXINGTON RD
LOUISVILLE KY
40207-2950
US

V. Phone/Fax

Practice location:
  • Phone: 502-305-6315
  • Fax:
Mailing address:
  • Phone: 592-305-6315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number1127369
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: