Healthcare Provider Details

I. General information

NPI: 1609245703
Provider Name (Legal Business Name): JESSICA SMITH IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2015
Last Update Date: 06/06/2026
Certification Date: 06/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 CASALOMA DR
FOREST VA
24551-1702
US

IV. Provider business mailing address

430 CASALOMA DR
FOREST VA
24551-1702
US

V. Phone/Fax

Practice location:
  • Phone: 434-851-8273
  • Fax: 434-205-9151
Mailing address:
  • Phone: 434-851-8273
  • Fax: 434-205-9151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-49420
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: