Provider Demographics
NPI:1588930598
Name:LUNDGREN, JESSICA A (MD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:A
Last Name:LUNDGREN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 HOSPITAL AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-1463
Mailing Address - Country:US
Mailing Address - Phone:814-375-4089
Mailing Address - Fax:814-375-4067
Practice Address - Street 1:145 HOSPITAL AVE STE 101
Practice Address - Street 2:
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-1463
Practice Address - Country:US
Practice Address - Phone:814-375-4089
Practice Address - Fax:814-375-4067
Is Sole Proprietor?:No
Enumeration Date:2012-03-25
Last Update Date:2022-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101264541207RE0101X
390200000X
PAMD474581207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMD474581OtherMEDICAL LICENSE
VA0101264541OtherMEDICAL LICENSE