Provider Demographics
NPI:1760293062
Name:LUSTRE, JEFFERSON
Entity type:Individual
Prefix:
First Name:JEFFERSON
Middle Name:
Last Name:LUSTRE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 N INGALLS ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-1568
Mailing Address - Country:US
Mailing Address - Phone:407-402-4446
Mailing Address - Fax:
Practice Address - Street 1:204 N INGALLS ST
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-1568
Practice Address - Country:US
Practice Address - Phone:407-402-4446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-15
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program