Provider Demographics
NPI:1558800771
Name:BENDIXEN, JACOB (ATC)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:BENDIXEN
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4314 TERRACE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-4935
Mailing Address - Country:US
Mailing Address - Phone:201-895-2093
Mailing Address - Fax:
Practice Address - Street 1:1900 W OLNEY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-1108
Practice Address - Country:US
Practice Address - Phone:215-951-1519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-21
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARTO0002902255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer