Healthcare Provider Details

I. General information

NPI: 1053761247
Provider Name (Legal Business Name): JERMAINE BENNETT LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2016
Last Update Date: 10/28/2025
Certification Date: 10/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2940 INLAND EMPIRE BLVD
ONTARIO CA
91764-4898
US

IV. Provider business mailing address

2940 INLAND EMPIRE BLVD
ONTARIO CA
91764-4898
US

V. Phone/Fax

Practice location:
  • Phone: 909-458-1350
  • Fax: 909-579-8149
Mailing address:
  • Phone: 909-458-1350
  • Fax: 909-579-8149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number134363
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: