Provider Demographics
NPI:1831490507
Name:LUND, E JOLENE (AUD)
Entity Type:Individual
Prefix:
First Name:E
Middle Name:JOLENE
Last Name:LUND
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1970 E 17TH ST STE 119
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8046
Mailing Address - Country:US
Mailing Address - Phone:208-522-3141
Mailing Address - Fax:208-542-1112
Practice Address - Street 1:1970 E 17TH ST STE 119
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8046
Practice Address - Country:US
Practice Address - Phone:208-522-3141
Practice Address - Fax:208-542-1112
Is Sole Proprietor?:No
Enumeration Date:2010-11-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAUD-2064237600000X
UT5888664-4101231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7149398OtherWA MEDICAID
ID1831490507OtherIDAHO MEDICAID
ID15814444OtherMEDICARE