Healthcare Provider Details

I. General information

NPI: 1902539596
Provider Name (Legal Business Name): JACOB EDWARD BENITES LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2022
Last Update Date: 03/05/2026
Certification Date: 03/05/2026
Deactivation Date: 07/20/2023
Reactivation Date: 02/24/2026

III. Provider practice location address

2177 E WARNER RD STE 101
TEMPE AZ
85284-3511
US

IV. Provider business mailing address

2003 N MCALLISTER AVE
TEMPE AZ
85288-1317
US

V. Phone/Fax

Practice location:
  • Phone: 480-573-0000
  • Fax:
Mailing address:
  • Phone: 520-400-0476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-23633
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: