Provider Demographics
NPI:1528502259
Name:LUSTGARTEN, JESSICA (BSN)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LUSTGARTEN
Suffix:
Gender:F
Credentials:BSN
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:WOODS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13499 HAZEL PL
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-6520
Mailing Address - Country:US
Mailing Address - Phone:480-330-8467
Mailing Address - Fax:
Practice Address - Street 1:2045 N FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80205-5437
Practice Address - Country:US
Practice Address - Phone:330-338-4545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-14
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN.1618902163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse