Provider Demographics
NPI:1891383691
Name:UNDERWOOD, JESSICA (IBCLC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:UNDERWOOD
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3134 W BDE MAKA SKA BLVD APT 210
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55416-6004
Mailing Address - Country:US
Mailing Address - Phone:763-607-1414
Mailing Address - Fax:
Practice Address - Street 1:5315 LYNDALE AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55419-1270
Practice Address - Country:US
Practice Address - Phone:612-223-8064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-06
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L-302131174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN