Provider Demographics
NPI:1104515311
Name:LUNDGREN, JENNIFER ANN (PMHNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:LUNDGREN
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 PERSHING AVE
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:IA
Mailing Address - Zip Code:51601-2355
Mailing Address - Country:US
Mailing Address - Phone:712-246-7285
Mailing Address - Fax:
Practice Address - Street 1:300 PERSHING AVE
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:IA
Practice Address - Zip Code:51601-2355
Practice Address - Country:US
Practice Address - Phone:712-246-7285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-03
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA155203163WG0000X
IAG1742692084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice