Provider Demographics
NPI:1073618708
Name:LIDSTROM, JENNIFER MARIE (MS,DC,PC)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:MARIE
Last Name:LIDSTROM
Suffix:
Gender:F
Credentials:MS,DC,PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19924 JETTON RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-8250
Mailing Address - Country:US
Mailing Address - Phone:704-876-8446
Mailing Address - Fax:704-896-8495
Practice Address - Street 1:19924 JETTON RD
Practice Address - Street 2:SUITE 101
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-8250
Practice Address - Country:US
Practice Address - Phone:704-876-8446
Practice Address - Fax:704-896-8495
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3249111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89085RNMedicaid
NC2457336AMedicare ID - Type Unspecified
NC89085RNMedicaid