Healthcare Provider Details

I. General information

NPI: 1619567641
Provider Name (Legal Business Name): JESSICA ROBYN DEASES RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2021
Last Update Date: 01/23/2021
Certification Date: 01/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 S LOOP 336 W STE 215
CONROE TX
77304-3701
US

IV. Provider business mailing address

51 NEW DAWN PL
THE WOODLANDS TX
77385-3679
US

V. Phone/Fax

Practice location:
  • Phone: 832-326-5858
  • Fax:
Mailing address:
  • Phone: 832-326-5858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number697945
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: