Provider Demographics
NPI:1891785804
Name:LUNDBERG, JEANETTE LILLIAN (PT)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:LILLIAN
Last Name:LUNDBERG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1789
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-1789
Mailing Address - Country:US
Mailing Address - Phone:360-428-6677
Mailing Address - Fax:360-428-7635
Practice Address - Street 1:300 E COLLEGE WAY
Practice Address - Street 2:SUITE B
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-5429
Practice Address - Country:US
Practice Address - Phone:360-428-6677
Practice Address - Fax:369-428-7635
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00000784225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7035843Medicaid
WAS76917Medicare UPIN
WA7035843Medicaid