Provider Demographics
NPI:1942236815
Name:JUNG, LAURIE T (PT)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:T
Last Name:JUNG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 DEMERS AVE
Mailing Address - Street 2:
Mailing Address - City:EAST GRAND FORKS
Mailing Address - State:MN
Mailing Address - Zip Code:56721-1833
Mailing Address - Country:US
Mailing Address - Phone:218-733-5858
Mailing Address - Fax:
Practice Address - Street 1:621 DEMERS AVE
Practice Address - Street 2:
Practice Address - City:EAST GRAND FORKS
Practice Address - State:MN
Practice Address - Zip Code:56721-1833
Practice Address - Country:US
Practice Address - Phone:218-733-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND884225100000X
MN4364225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND51158Medicaid
64-06630OtherMEDICA
MN547G3JUOtherBC/BS
2685053OtherUNITED HEALTH CARE
ND26929OtherBC/BS
MN353264000Medicaid
MN353264000Medicaid
P00355501Medicare PIN
2685053OtherUNITED HEALTH CARE