Provider Demographics
NPI:1861808495
Name:LUNDBERG, JILL (RYT)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:LUNDBERG
Suffix:
Gender:F
Credentials:RYT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5927 SCHUMANN DR
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53711-5104
Mailing Address - Country:US
Mailing Address - Phone:608-444-7035
Mailing Address - Fax:
Practice Address - Street 1:5927 SCHUMANN DR
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:WI
Practice Address - Zip Code:53711-5104
Practice Address - Country:US
Practice Address - Phone:608-444-7035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-02
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
117062171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
117062OtherYOGA ALLIANCE REGISTRY ID