Provider Demographics
NPI:1639555600
Name:LUSTBADER, JENNIFER (CMR)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LUSTBADER
Suffix:
Gender:F
Credentials:CMR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14760 SW FOREST DR
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97007-5117
Mailing Address - Country:US
Mailing Address - Phone:503-860-7481
Mailing Address - Fax:
Practice Address - Street 1:14760 SW FOREST DR
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97007-5117
Practice Address - Country:US
Practice Address - Phone:503-860-7481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-31
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15-CRM-111175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR15-CRM-111OtherUNDETERMINED