MEDICARE: JODI NUSSBAUM RN, BSN, 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)	RN60762981	WA

General Provider Information

NPI Number	:	1346023538
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JODI NUSSBAUM RN, BSN, IBCLC

Provider Business Mailing Address
First Line	:	522 W RIVERSIDE AVE # 8120
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99201-0580
Country	:	US
Telephone Number	:	425-233-1471
Fax Number	:

Provider Business Practice Location Address
First Line	:	1621 W CARROLL AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-2501
Country	:	US
Telephone Number	:	425-233-1471
Fax Number	:

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

Provider Enumeration Date	:	08/14/2023
Last Update Date	:	08/14/2023

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