Provider Demographics
NPI:1962099804
Name:WILLIS, JENICA MARISSA (LM, CPM, LVN, IBCLC)
Entity type:Individual
Prefix:MRS
First Name:JENICA
Middle Name:MARISSA
Last Name:WILLIS
Suffix:
Gender:
Credentials:LM, CPM, LVN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1031 17TH STREET
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93301
Mailing Address - Country:US
Mailing Address - Phone:661-234-9894
Mailing Address - Fax:661-360-6243
Practice Address - Street 1:1031 17TH STREET
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-6172
Practice Address - Country:US
Practice Address - Phone:661-234-9894
Practice Address - Fax:661-360-6243
Is Sole Proprietor?:No
Enumeration Date:2020-12-27
Last Update Date:2025-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA286953164X00000X
CAL-302379174N00000X
CALM764176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No164X00000XNursing Service ProvidersLicensed Vocational Nurse
No174N00000XOther Service ProvidersLactation Consultant, Non-RN