Provider Demographics
NPI:1497422174
Name:SUNDERLAGE, JACOB MICHAEL (DC)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:MICHAEL
Last Name:SUNDERLAGE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 S MAIN ST STE 5
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-6628
Mailing Address - Country:US
Mailing Address - Phone:540-951-6900
Mailing Address - Fax:
Practice Address - Street 1:7350 PEPPERS FERRY BLVD STE B
Practice Address - Street 2:
Practice Address - City:FAIRLAWN
Practice Address - State:VA
Practice Address - Zip Code:24141-8999
Practice Address - Country:US
Practice Address - Phone:540-731-4357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104-557743111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor