MEDICARE: MRS. JESSICA SMITH 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	163WL0100X	Lactation Consultant (Registered Nurse)	L-49420	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	L-49420	OTHER	VA	LACTATION CONSULTANT (IBCLC)
2	0001167682	OTHER	VA	RN

General Provider Information

NPI Number	:	1609245703
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JESSICA SMITH IBCLC

Provider Business Mailing Address
First Line	:	430 CASALOMA DR
Second Line	:
City	:	FOREST
State	:	VA
Zip	:	24551-1702
Country	:	US
Telephone Number	:	434-851-8273
Fax Number	:	434-205-9151

Provider Business Practice Location Address
First Line	:	430 CASALOMA DR
Second Line	:
City	:	FOREST
State	:	VA
Zip	:	24551-1702
Country	:	US
Telephone Number	:	434-851-8273
Fax Number	:	434-205-9151

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

Provider Enumeration Date	:	09/18/2015
Last Update Date	:	06/06/2026

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