Provider Demographics
NPI:1902305667
Name:JORGENSEN-PERRY, ANDREA LYNN (IBCLC)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:LYNN
Last Name:JORGENSEN-PERRY
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:
Other - Last Name:JORGENSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:IBCLC
Mailing Address - Street 1:85 GLENELLEN RD
Mailing Address - Street 2:
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-5107
Mailing Address - Country:US
Mailing Address - Phone:978-360-1009
Mailing Address - Fax:
Practice Address - Street 1:85 GLENELLEN RD
Practice Address - Street 2:
Practice Address - City:WEST ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02132-5107
Practice Address - Country:US
Practice Address - Phone:978-360-1009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-08
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
Provider Identifiers
StateIdentifier IDID TypeIssuer
L-33942OtherIBLCE