Provider Demographics
NPI:1710554175
Name:EDMONDS, JESSICA (CLC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:EDMONDS
Suffix:
Gender:F
Credentials:CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 DENNIN DR
Mailing Address - Street 2:
Mailing Address - City:MENANDS
Mailing Address - State:NY
Mailing Address - Zip Code:12204-1203
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 DENNIN DR
Practice Address - Street 2:
Practice Address - City:MENANDS
Practice Address - State:NY
Practice Address - Zip Code:12204-1203
Practice Address - Country:US
Practice Address - Phone:518-992-6105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-04
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA330912174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN