Provider Demographics
NPI:1972114460
Name:LANDSTEDT, JOLEENA MICHAL
Entity Type:Individual
Prefix:
First Name:JOLEENA
Middle Name:MICHAL
Last Name:LANDSTEDT
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 1:4666 W SAN SALVO DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-5019
Mailing Address - Country:US
Mailing Address - Phone:619-647-4471
Mailing Address - Fax:
Practice Address - Street 1:4666 W SAN SALIVO DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-5019
Practice Address - Country:US
Practice Address - Phone:619-647-4471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-10
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID12043824171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach