Healthcare Provider Details

I. General information

NPI: 1679086458
Provider Name (Legal Business Name): LEAH ELIZABETH JOLLY IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2017
Last Update Date: 11/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2017 BROADWAY ST STE B
PEARLAND TX
77581-5501
US

IV. Provider business mailing address

6104 JORDAN DR
PEARLAND TX
77584-8024
US

V. Phone/Fax

Practice location:
  • Phone: 713-496-2223
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-15977
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: