MEDICARE: JENNIFER LIDSTROM MS DC PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	3249	NC
2	261QM1300X	Multi-Specialty Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033125240
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JENNIFER LIDSTROM MS DC PC

Provider Business Mailing Address
First Line	:	11220 TREYNORTH DR STE A
Second Line	:
City	:	CORNELIUS
State	:	NC
Zip	:	28031-8198
Country	:	US
Telephone Number	:	704-896-8446
Fax Number	:	704-896-8495

Provider Business Practice Location Address
First Line	:	11220 TREYNORTH DR STE A
Second Line	:
City	:	CORNELIUS
State	:	NC
Zip	:	28031-8198
Country	:	US
Telephone Number	:	704-896-8446
Fax Number	:	704-896-8495

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JENNIFER MARIE LIDSTROM
Credential	:	DC
Telephone Number	:	704-896-8446

Provider Enumeration Date	:	07/31/2006
Last Update Date	:	01/27/2026

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