Provider Demographics
NPI:1598251175
Name:LUNDORF, JACOB EDWARD (AGNP)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:EDWARD
Last Name:LUNDORF
Suffix:
Gender:M
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 W KIRKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404-5046
Mailing Address - Country:US
Mailing Address - Phone:574-850-2069
Mailing Address - Fax:
Practice Address - Street 1:2100 S LIBERTY DR STE B
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403
Practice Address - Country:US
Practice Address - Phone:812-336-5723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-06
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5010695363L00000X
IN71009487B363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner