MEDICARE: DR. JANICE A. BENNETT PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TA0400X	Addiction (Substance Use Disorder) Psychologist	24574	TX
2	103TC0700X	Clinical Psychologist	24574	TX
3	103T00000X	Psychologist	24574	TX
4	103TP2701X	Group Psychotherapy Psychologist	24574	TX

General Provider Information

NPI Number	:	1285642405
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JANICE A. BENNETT PH.D.

Provider Business Mailing Address
First Line	:	6000 WESTERN PL
Second Line	:	STE. 300
City	:	FT WORTH
State	:	TX
Zip	:	76107-4607
Country	:	US
Telephone Number	:	817-570-2248
Fax Number	:	817-570-2231

Provider Business Practice Location Address
First Line	:	6000 WESTERN PL
Second Line	:	STE. 300
City	:	FT WORTH
State	:	TX
Zip	:	76107-4607
Country	:	US
Telephone Number	:	817-570-2248
Fax Number	:	817-570-2231

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2006
Last Update Date	:	09/11/2025

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