MEDICARE: JENNA MICHELLE BENOIT PA-C

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	363A00000X	Physician Assistant	085.004782	IL

General Provider Information

NPI Number	:	1790110666
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNA MICHELLE BENOIT PA-C

Provider Business Mailing Address
First Line	:	1255 N SANDBURG TER
Second Line	:	APT 1503
City	:	CHICAGO
State	:	IL
Zip	:	60610-8253
Country	:	US
Telephone Number	:	248-890-5063
Fax Number	:

Provider Business Practice Location Address
First Line	:	2400 N ASHLAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-2021
Country	:	US
Telephone Number	:	773-270-5600
Fax Number	:	773-360-7378

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

Provider Enumeration Date	:	09/10/2013
Last Update Date	:	11/07/2016

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