Provider Demographics
NPI:1750953840
Name:LUNDBERG, JORDAN NICOLE (DPT)
Entity type:Individual
Prefix:MS
First Name:JORDAN
Middle Name:NICOLE
Last Name:LUNDBERG
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1780 52ND STREET EAST
Mailing Address - Street 2:APT #103
Mailing Address - City:INVER GROVE HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55077
Mailing Address - Country:US
Mailing Address - Phone:715-410-8526
Mailing Address - Fax:
Practice Address - Street 1:5740 BROOKLYN BLVD
Practice Address - Street 2:#100
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55429
Practice Address - Country:US
Practice Address - Phone:763-561-4045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-16
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12279225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist