Provider Demographics
NPI:1982632733
Name:LUNDHOLM, JEAN KAY (PH D)
Entity Type:Individual
Prefix:MRS
First Name:JEAN
Middle Name:KAY
Last Name:LUNDHOLM
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 N 2ND ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54022-3706
Mailing Address - Country:US
Mailing Address - Phone:715-425-8899
Mailing Address - Fax:715-425-5590
Practice Address - Street 1:215 N 2ND ST
Practice Address - Street 2:SUITE 101
Practice Address - City:RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54022-3706
Practice Address - Country:US
Practice Address - Phone:715-425-8899
Practice Address - Fax:715-425-5590
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1695 057103T00000X
MNLP1360103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39263900Medicaid
366502OtherPREFERRED ONE
08631LUOtherBLUE CROSS MN