Provider Demographics
NPI:1972005361
Name:BUNDY, JAKE (MOTR/L)
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:BUNDY
Suffix:
Gender:M
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5082 BRYLEE WAY
Mailing Address - Street 2:
Mailing Address - City:IONA
Mailing Address - State:ID
Mailing Address - Zip Code:83427-4908
Mailing Address - Country:US
Mailing Address - Phone:435-669-2438
Mailing Address - Fax:
Practice Address - Street 1:560 MEMORIAL DR STE B
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4073
Practice Address - Country:US
Practice Address - Phone:208-235-4263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-01
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-1457225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist