Provider Demographics
NPI:1396348280
Name:LUNDQUIST, JAKE PAUL (FNP-C)
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:PAUL
Last Name:LUNDQUIST
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 244
Mailing Address - Street 2:
Mailing Address - City:MC CAYSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30555-0244
Mailing Address - Country:US
Mailing Address - Phone:716-969-5687
Mailing Address - Fax:
Practice Address - Street 1:63 PLEASANT HILL RD
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512-2291
Practice Address - Country:US
Practice Address - Phone:706-745-2229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-21
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN244697363LF0000X
GAF09201627363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily