Provider Demographics
NPI:1811420334
Name:BENDER, JACLYN MARIE (DO)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:MARIE
Last Name:BENDER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:MARIE
Other - Last Name:PEICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-4400
Mailing Address - Fax:
Practice Address - Street 1:2925 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-1321
Practice Address - Country:US
Practice Address - Phone:612-863-4000
Practice Address - Fax:763-236-3026
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-11
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN30050208000000X
390200000X
MN71262208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty