Provider Demographics
NPI:1417127432
Name:BENTLEY, JACOB ERIC (CO, LO)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:ERIC
Last Name:BENTLEY
Suffix:
Gender:M
Credentials:CO, LO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1619 JOHN ORR DR
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-3640
Mailing Address - Country:US
Mailing Address - Phone:229-386-9829
Mailing Address - Fax:229-386-9830
Practice Address - Street 1:127 ENTERPRISE PATH
Practice Address - Street 2:STE 403
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-2697
Practice Address - Country:US
Practice Address - Phone:678-384-1921
Practice Address - Fax:678-384-1922
Is Sole Proprietor?:No
Enumeration Date:2008-03-05
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA14222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist