Healthcare Provider Details

I. General information

NPI: 1457701682
Provider Name (Legal Business Name): JENNIFER YORK IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2016
Last Update Date: 06/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

338 S MAIN ST
SAINT CHARLES MO
63301-3435
US

IV. Provider business mailing address

10 HASTINGS CT
SAINT CHARLES MO
63301-5511
US

V. Phone/Fax

Practice location:
  • Phone: 636-362-4338
  • Fax:
Mailing address:
  • Phone: 773-556-8065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-101176
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: