Basic Information
Provider Information
NPI: 1427320605
EntityType: 2
ReplacementNPI:  
OrganizationName: JENNIFER LUNDY FAMILY THERAPY, INC.
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: POSITIVE CHANGE COUNSELING CENTER
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 5480 BALTIMORE DR STE 250
Address2:  
City: LA MESA
State: CA
PostalCode: 919422066
CountryCode: US
TelephoneNumber: 6197336414
FaxNumber: 6193033306
Practice Location
Address1: 5480 BALTIMORE DR STE 250
Address2:  
City: LA MESA
State: CA
PostalCode: 919422066
CountryCode: US
TelephoneNumber: 6197336414
FaxNumber: 6193033306
Other Information
ProviderEnumerationDate: 02/02/2012
LastUpdateDate: 03/12/2014
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: LUNDY-AGUERRE
AuthorizedOfficialFirstName: JENNIFER
AuthorizedOfficialMiddleName: LYNN
AuthorizedOfficialTitleorPosition: OWNER
AuthorizedOfficialTelephone: 6197336414
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: MFT
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
106H00000X42025CAN193400000X MULTIPLE SINGLE SPECIALTY GROUPBehavioral Health & Social Service ProvidersMarriage & Family Therapist 
103TC0700X21402CAY193400000X MULTIPLE SINGLE SPECIALTY GROUPBehavioral Health & Social Service ProvidersPsychologistClinical

No ID Information.


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