Provider Demographics
NPI:1649710732
Name:TANGEN, JESSICA RAE (IBCLC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:RAE
Last Name:TANGEN
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 1:449 OVERLOOK PASS
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-7547
Mailing Address - Country:US
Mailing Address - Phone:320-221-0443
Mailing Address - Fax:
Practice Address - Street 1:449 OVERLOOK PASS
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-7547
Practice Address - Country:US
Practice Address - Phone:320-221-0443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-08
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L-49688174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN