Healthcare Provider Details

I. General information

NPI: 1427953314
Provider Name (Legal Business Name): JILLIAN MAXWELL IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2026
Last Update Date: 10/10/2026
Certification Date: 10/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

556 N OAK ST
MASSAPEQUA NY
11758-2767
US

IV. Provider business mailing address

556 N OAK ST
MASSAPEQUA NY
11758-2767
US

V. Phone/Fax

Practice location:
  • Phone: 516-672-0694
  • Fax:
Mailing address:
  • Phone: 516-672-0694
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number322299
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: