Provider Demographics
NPI:1114603677
Name:LUNDBERG, JORDAN RHAE (DPT)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:RHAE
Last Name:LUNDBERG
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 W FARIBAULT ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55803-1729
Mailing Address - Country:US
Mailing Address - Phone:218-841-7092
Mailing Address - Fax:
Practice Address - Street 1:2001 BLAISDELL AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-2414
Practice Address - Country:US
Practice Address - Phone:952-993-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN131112251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic