Healthcare Provider Details

I. General information

NPI: 1306421482
Provider Name (Legal Business Name): JESSICA BENTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2021
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6196 LAKE GRAY BLVD STE 116
JACKSONVILLE FL
32244-5867
US

IV. Provider business mailing address

PO BOX 631278
CINCINNATI OH
45263-1278
US

V. Phone/Fax

Practice location:
  • Phone: 800-356-4049
  • Fax: 941-485-0519
Mailing address:
  • Phone: 800-356-4049
  • Fax: 941-485-0519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-26-88470
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: