Provider Demographics
NPI:1902308323
Name:MANSHRECK, JAMIE K (RN, IBCLC)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:K
Last Name:MANSHRECK
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:0N052 PAULEY SQ
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-4442
Mailing Address - Country:US
Mailing Address - Phone:630-408-7522
Mailing Address - Fax:
Practice Address - Street 1:0N052 PAULEY SQ
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-4442
Practice Address - Country:US
Practice Address - Phone:630-408-7522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-01
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041347459163W00000X
ILL-45266163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No163W00000XNursing Service ProvidersRegistered Nurse