Provider Demographics
NPI:1912446451
Name:BEDUNA, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:BEDUNA
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 1:9900 GILMORE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47448-9731
Mailing Address - Country:US
Mailing Address - Phone:812-322-0313
Mailing Address - Fax:812-610-1814
Practice Address - Street 1:500 S MORTON ST
Practice Address - Street 2:SUITE 010
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2460
Practice Address - Country:US
Practice Address - Phone:812-322-0313
Practice Address - Fax:812-610-1814
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-16
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-16-22847103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst