Provider Demographics
NPI:1295549251
Name:BENDORF, JACOB MARCUS
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:MARCUS
Last Name:BENDORF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14814 HUNTING PATH PL
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20120-1230
Mailing Address - Country:US
Mailing Address - Phone:571-398-4394
Mailing Address - Fax:
Practice Address - Street 1:580 MASSIE RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-1738
Practice Address - Country:US
Practice Address - Phone:735-492-4434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-01
Last Update Date:2025-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program