Provider Demographics
NPI:1588372379
Name:POTTER, JENNIFER MARIE (IBCLC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:POTTER
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:387 MAGNOLIA AVE # 103-137
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-3307
Mailing Address - Country:US
Mailing Address - Phone:951-329-1812
Mailing Address - Fax:
Practice Address - Street 1:897 E CHASE DR
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92881-3940
Practice Address - Country:US
Practice Address - Phone:951-394-2087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-09
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAL-302489174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN