MEDICARE: JENNA FORESTER RN BSN IBCLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	0001218672	VA
2	174400000X	Specialist	L-46303	VA

General Provider Information

NPI Number	:	1962850677
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNA FORESTER RN BSN IBCLC

Provider Business Mailing Address
First Line	:	15736 VISTA DR
Second Line	:
City	:	MONTCLAIR
State	:	VA
Zip	:	22025-1812
Country	:	US
Telephone Number	:	540-320-0118
Fax Number	:

Provider Business Practice Location Address
First Line	:	15736 VISTA DR
Second Line	:
City	:	MONTCLAIR
State	:	VA
Zip	:	22025-1812
Country	:	US
Telephone Number	:	540-320-0118
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/03/2016
Last Update Date	:	06/03/2016

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