1750953840 NPI number — MS. JORDAN NICOLE LUNDBERG DPT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750953840 NPI number — MS. JORDAN NICOLE LUNDBERG DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUNDBERG
Provider First Name:
JORDAN
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750953840
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/16/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1780 52ND STREET EAST
Provider Second Line Business Mailing Address:
APT #103
Provider Business Mailing Address City Name:
INVER GROVE HEIGHTS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55077
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-410-8526
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5740 BROOKLYN BLVD
Provider Second Line Business Practice Location Address:
#100
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55429
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-561-4045
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/16/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  12279 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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