Healthcare Provider Details

I. General information

NPI: 1104553395
Provider Name (Legal Business Name): JESSICA J TANG FNP-BC, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2022
Last Update Date: 07/08/2025
Certification Date: 07/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 WARREN ST
NEWTON MA
02459-2065
US

IV. Provider business mailing address

PO BOX 3158
PORTLAND OR
97208-3158
US

V. Phone/Fax

Practice location:
  • Phone: 800-998-7042
  • Fax: 818-724-7704
Mailing address:
  • Phone: 503-215-6494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-314297
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10000143
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: