Provider Demographics
NPI:1356076533
Name:BUSTAMENTE, JESSICA (IBCLC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BUSTAMENTE
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 1:1806 EDGECUMBE DR
Mailing Address - Street 2:
Mailing Address - City:SITKA
Mailing Address - State:AK
Mailing Address - Zip Code:99835-9614
Mailing Address - Country:US
Mailing Address - Phone:360-775-8623
Mailing Address - Fax:
Practice Address - Street 1:1806 EDGECUMBE DR
Practice Address - Street 2:
Practice Address - City:SITKA
Practice Address - State:AK
Practice Address - Zip Code:99835-9614
Practice Address - Country:US
Practice Address - Phone:360-775-8623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-20
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L-303919174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN