Provider Demographics
NPI:1467785253
Name:LUNDGREN, JAN HARRIS (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:JAN
Middle Name:HARRIS
Last Name:LUNDGREN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:MS
Other - First Name:JAN
Other - Middle Name:BOYD
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:6509 WYNBROOK WAY
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-2370
Mailing Address - Country:US
Mailing Address - Phone:941-928-3766
Mailing Address - Fax:
Practice Address - Street 1:208 MERCER MILL RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:NC
Practice Address - Zip Code:28337
Practice Address - Country:US
Practice Address - Phone:910-862-6400
Practice Address - Fax:910-247-2413
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-10
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7674235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist