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General NPI Number Information
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NPI Number | 1205304607
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Entity Type | Individual
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Provider Name | JACK BUNDY
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Gender | Male
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Dates
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Enumeration Date | 11/05/2018
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Last Update Date | 07/22/2025
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Provider Practice Location Address
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Address Line | 5923 RIDGEBURY BLVD
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City | CLEVELAND
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State | OH
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Zip | 44124-1638
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Country | US
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Telephone | 440-637-3599
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Fax |
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Provider Business Mailing Address
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Address Line | DEPT 781625 PO BOX 78000
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City | DETROIT
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State | MI
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Zip | 48278-1625
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Country | US
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Telephone | 614-355-8004
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number | BACB471643
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License Number State | OH
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