Provider Demographics
NPI:1134522824
Name:LUNDBERG, JAYME
Entity type:Individual
Prefix:
First Name:JAYME
Middle Name:
Last Name:LUNDBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JAYME
Other - Middle Name:
Other - Last Name:REZAC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:24110 AIKEN SWITCH ROAD
Mailing Address - Street 2:
Mailing Address - City:ONAGA
Mailing Address - State:KS
Mailing Address - Zip Code:66521
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:426A MCCALL ROAD
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502
Practice Address - Country:US
Practice Address - Phone:785-776-0670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-08
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-02522225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant