Healthcare Provider Details

I. General information

NPI: 1346854189
Provider Name (Legal Business Name): KATHLEEN NICOLE JENNINGS RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2020
Last Update Date: 08/31/2020
Certification Date: 08/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 JOSEPH SIEWICK DR
FAIRFAX VA
22033-1709
US

IV. Provider business mailing address

12602 JAMES BERGEN WAY
FAIRFAX VA
22033-4382
US

V. Phone/Fax

Practice location:
  • Phone: 703-391-3600
  • Fax:
Mailing address:
  • Phone: 703-655-5049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number0001203763
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-19053
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: