Healthcare Provider Details

I. General information

NPI: 1427320605
Provider Name (Legal Business Name): JENNIFER LUNDY FAMILY THERAPY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2012
Last Update Date: 03/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5480 BALTIMORE DR STE 250
LA MESA CA
91942-2066
US

IV. Provider business mailing address

5480 BALTIMORE DR STE 250
LA MESA CA
91942-2066
US

V. Phone/Fax

Practice location:
  • Phone: 619-733-6414
  • Fax: 619-303-3306
Mailing address:
  • Phone: 619-733-6414
  • Fax: 619-303-3306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number42025
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number21402
License Number StateCA

VIII. Authorized Official

Name: JENNIFER LYNN LUNDY-AGUERRE
Title or Position: OWNER
Credential: MFT
Phone: 619-733-6414