Healthcare Provider Details

I. General information

NPI: 1598251175
Provider Name (Legal Business Name): JACOB EDWARD LUNDORF NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2018
Last Update Date: 08/06/2025
Certification Date: 08/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 S LIBERTY DR STE B
BLOOMINGTON IN
47403
US

IV. Provider business mailing address

706 W KIRKWOOD AVE
BLOOMINGTON IN
47404-5046
US

V. Phone/Fax

Practice location:
  • Phone: 812-336-5723
  • Fax:
Mailing address:
  • Phone: 574-850-2069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5010695
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number71009487A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71009487B
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: