Provider Demographics
NPI:1366593428
Name:LUNDBERG, JAN MARIE (DC)
Entity type:Individual
Prefix:DR
First Name:JAN MARIE
Middle Name:
Last Name:LUNDBERG
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 7TH AVE N
Mailing Address - Street 2:
Mailing Address - City:TIERRA VERDE
Mailing Address - State:FL
Mailing Address - Zip Code:33715-1819
Mailing Address - Country:US
Mailing Address - Phone:727-510-0215
Mailing Address - Fax:
Practice Address - Street 1:416 7TH AVE N
Practice Address - Street 2:
Practice Address - City:TIERRA VERDE
Practice Address - State:FL
Practice Address - Zip Code:33715-1819
Practice Address - Country:US
Practice Address - Phone:727-510-0215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 5952111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL22332Medicare ID - Type Unspecified