Healthcare Provider Details

I. General information

NPI: 1346023538
Provider Name (Legal Business Name): JODI NUSSBAUM RN, BSN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2023
Last Update Date: 08/14/2023
Certification Date: 08/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1621 W CARROLL AVE
CHICAGO IL
60612-2501
US

IV. Provider business mailing address

522 W RIVERSIDE AVE # 8120
SPOKANE WA
99201-0580
US

V. Phone/Fax

Practice location:
  • Phone: 425-233-1471
  • Fax:
Mailing address:
  • Phone: 425-233-1471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberRN60762981
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: