Provider Demographics
NPI:1790409241
Name:LUNDBERG, JESSICA PAULINE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:PAULINE
Last Name:LUNDBERG
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 1:6500 EP TRUE PKWY APT 3205
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-5263
Mailing Address - Country:US
Mailing Address - Phone:515-210-4297
Mailing Address - Fax:
Practice Address - Street 1:6000 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-8203
Practice Address - Country:US
Practice Address - Phone:515-241-8686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-28
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA86116754133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered