Provider Demographics
NPI:1861599565
Name:LUNDQUIST, JERILYN MARIE (LCSW)
Entity type:Individual
Prefix:MS
First Name:JERILYN
Middle Name:MARIE
Last Name:LUNDQUIST
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1134 DOW ST
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37130-2486
Mailing Address - Country:US
Mailing Address - Phone:615-594-0787
Mailing Address - Fax:615-890-8344
Practice Address - Street 1:1134 DOW ST
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37130-2486
Practice Address - Country:US
Practice Address - Phone:615-594-0787
Practice Address - Fax:615-890-8344
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW12031041C0700X
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3922151Medicare ID - Type Unspecified