Provider Demographics
NPI:1124854799
Name:LUNDEEN, JENNIFER MICHELLE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MICHELLE
Last Name:LUNDEEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 W 120TH AVE # 237
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80234-2879
Mailing Address - Country:US
Mailing Address - Phone:303-887-2807
Mailing Address - Fax:
Practice Address - Street 1:1035 EL RANCHO RD
Practice Address - Street 2:
Practice Address - City:EVERGREEN
Practice Address - State:CO
Practice Address - Zip Code:80439-8238
Practice Address - Country:US
Practice Address - Phone:720-295-3790
Practice Address - Fax:877-400-4480
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-11
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO251S00000X251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO251S00000XMedicaid