Provider Demographics
NPI:1861740581
Name:VANDERBURG, JENNIFER L (LMT)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:L
Last Name:VANDERBURG
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 111
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:MT
Mailing Address - Zip Code:59831
Mailing Address - Country:US
Mailing Address - Phone:406-529-1958
Mailing Address - Fax:
Practice Address - Street 1:240 N. HIGGINS #11
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802
Practice Address - Country:US
Practice Address - Phone:406-529-1958
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-28
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLMT-LMT-LIC-675172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist