MEDICARE: JESSICA BLAIR SIMANDJUNTAK RN, 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)	95176001	CA
2	163WL0100X	Lactation Consultant (Registered Nurse)	L-308269	CA

General Provider Information

NPI Number	:	1508717216
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA BLAIR SIMANDJUNTAK RN, IBCLC

Provider Business Mailing Address
First Line	:	151 ORANGE PARK
Second Line	:
City	:	REDLANDS
State	:	CA
Zip	:	92374-5543
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	151 ORANGE PARK
Second Line	:
City	:	REDLANDS
State	:	CA
Zip	:	92374-5543
Country	:	US
Telephone Number	:	909-810-8188
Fax Number	:

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

Provider Enumeration Date	:	02/07/2026
Last Update Date	:	02/07/2026

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