Provider Demographics
NPI:1417686684
Name:LUNDGREN, JENNIFER M (PAC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:LUNDGREN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11311 BRIDGEPORT WAY SW STE 205
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-3051
Mailing Address - Country:US
Mailing Address - Phone:253-985-6490
Mailing Address - Fax:253-985-6488
Practice Address - Street 1:11311 BRIDGEPORT WAY SW STE 205
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-3051
Practice Address - Country:US
Practice Address - Phone:253-985-6490
Practice Address - Fax:253-985-6488
Is Sole Proprietor?:No
Enumeration Date:2022-06-05
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61448964363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2284734Medicaid