Basic Information
| Provider Information | |||||||||
| NPI: | 1588930598 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUNDGREN | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 145 HOSPITAL AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | DU BOIS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 158011463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143754089 | ||||||||
| FaxNumber: | 8143754067 | ||||||||
| Practice Location | |||||||||
| Address1: | 145 HOSPITAL AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | DU BOIS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 158011463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143754089 | ||||||||
| FaxNumber: | 8143754067 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2012 | ||||||||
| LastUpdateDate: | 08/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | 0101264541 | VA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RE0101X | MD474581 | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | MD474581 | 01 | PA | MEDICAL LICENSE | OTHER | 0101264541 | 01 | VA | MEDICAL LICENSE | OTHER |