Provider Demographics
NPI:1861283079
Name:PEMBERTON, JENISSA
Entity type:Individual
Prefix:
First Name:JENISSA
Middle Name:
Last Name:PEMBERTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10516 EST LA REINE
Mailing Address - Street 2:
Mailing Address - City:KINGSHILL
Mailing Address - State:VI
Mailing Address - Zip Code:00850-9643
Mailing Address - Country:US
Mailing Address - Phone:321-327-1037
Mailing Address - Fax:
Practice Address - Street 1:10516 EST LA REINE
Practice Address - Street 2:
Practice Address - City:KINGSHILL
Practice Address - State:VI
Practice Address - Zip Code:00850-9643
Practice Address - Country:US
Practice Address - Phone:321-327-1037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-15
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No174N00000XOther Service ProvidersLactation Consultant, Non-RN