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
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 42025 | CA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   | 103TC0700X | 21402 | CA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.