Provider Demographics
NPI:1336198464
Name:SUNDBY, JESSICA RENEE (DC)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:RENEE
Last Name:SUNDBY
Suffix:
Gender:F
Credentials:DC
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 158
Mailing Address - Street 2:
Mailing Address - City:LAMOURE
Mailing Address - State:ND
Mailing Address - Zip Code:58458-0158
Mailing Address - Country:US
Mailing Address - Phone:701-883-4353
Mailing Address - Fax:701-883-4228
Practice Address - Street 1:100 1ST AVE SW
Practice Address - Street 2:
Practice Address - City:LAMOURE
Practice Address - State:ND
Practice Address - Zip Code:58458-0158
Practice Address - Country:US
Practice Address - Phone:701-883-4353
Practice Address - Fax:701-883-4228
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND767111N00000X
AK464111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND13651Medicaid
ND13655Medicaid
ND26403OtherBLUE CROSS
NDV07652Medicare UPIN
ND711724Medicare ID - Type UnspecifiedGROUP MEDICARE
ND13655Medicaid