Provider Demographics
NPI:1699722546
Name:LUNDEEN, JANICE ANNETTE (CSW)
Entity type:Individual
Prefix:MS
First Name:JANICE
Middle Name:ANNETTE
Last Name:LUNDEEN
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:PHENIX CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36869-5436
Mailing Address - Country:US
Mailing Address - Phone:406-250-9574
Mailing Address - Fax:
Practice Address - Street 1:2275 W BROADWAY ST.
Practice Address - Street 2:SUITE G.
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-2902
Practice Address - Country:US
Practice Address - Phone:208-524-7400
Practice Address - Fax:208-534-5715
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-41069104100000X
GA0088231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT70205OtherBLUE CROSS BLUE SHIELD
MT0502707Medicaid