Provider Demographics
NPI:1063857407
Name:JEDRZEJEK, TRACEY (MA, CLE, IBCLC)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:JEDRZEJEK
Suffix:
Gender:F
Credentials:MA, CLE, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2716 HALLMARK DR
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94002-2914
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2716 HALLMARK DR
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:CA
Practice Address - Zip Code:94002-2914
Practice Address - Country:US
Practice Address - Phone:650-303-5953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-29
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA11175150174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN