Healthcare Provider Details

I. General information

NPI: 1912446451
Provider Name (Legal Business Name): JACOB BEDUNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2017
Last Update Date: 02/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S MORTON ST SUITE 010
BLOOMINGTON IN
47403-2460
US

IV. Provider business mailing address

9900 GILMORE RIDGE RD
NASHVILLE IN
47448-9731
US

V. Phone/Fax

Practice location:
  • Phone: 812-322-0313
  • Fax: 812-610-1814
Mailing address:
  • Phone: 812-322-0313
  • Fax: 812-610-1814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-16-22847
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: