Provider Demographics
NPI:1912242983
Name:PUDENZ, JACOB EDWARD (DC)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:EDWARD
Last Name:PUDENZ
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 1:13 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEWHALL
Mailing Address - State:IA
Mailing Address - Zip Code:52315-8800
Mailing Address - Country:US
Mailing Address - Phone:319-328-9061
Mailing Address - Fax:
Practice Address - Street 1:13 MAIN ST
Practice Address - Street 2:
Practice Address - City:NEWHALL
Practice Address - State:IA
Practice Address - Zip Code:52315-8800
Practice Address - Country:US
Practice Address - Phone:319-328-9061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-03
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA007603111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor