Provider Demographics
NPI:1790177285
Name:LUNDGREN, JILL ELIZABETH
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:ELIZABETH
Last Name:LUNDGREN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 W HORIZON RIDGE PKWY STE 160
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89012-3503
Mailing Address - Country:US
Mailing Address - Phone:702-566-8266
Mailing Address - Fax:
Practice Address - Street 1:1510 W HORIZON RIDGE PKWY STE 160
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89012-3503
Practice Address - Country:US
Practice Address - Phone:702-566-8266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-20
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSP-1692235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist