Healthcare Provider Details

I. General information

NPI: 1346578986
Provider Name (Legal Business Name): JONATHAN F LUNDY PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2009
Last Update Date: 04/08/2022
Certification Date: 04/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7010 E BOGARD RD
WASILLA AK
99654-4711
US

IV. Provider business mailing address

PO BOX 4105
PORTLAND OR
97208-4105
US

V. Phone/Fax

Practice location:
  • Phone: 907-746-4748
  • Fax:
Mailing address:
  • Phone: 866-907-1068
  • Fax: 425-917-9141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number121067
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: