Healthcare Provider Details

I. General information

NPI: 1306661087
Provider Name (Legal Business Name): CAMILLE JORGENSEN IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2024
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4873 S POPLAR WAY # B201
MAPLETON UT
84664-5085
US

IV. Provider business mailing address

4873 S POPLAR WAY # B201
MAPLETON UT
84664-5085
US

V. Phone/Fax

Practice location:
  • Phone: 425-528-6595
  • Fax:
Mailing address:
  • Phone: 425-528-6595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175M00000X
TaxonomyLay Midwife
License Number
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-314354
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: