Healthcare Provider Details

I. General information

NPI: 1982815171
Provider Name (Legal Business Name): JANE ELLEN BENSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2007
Last Update Date: 05/12/2021
Certification Date: 05/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12084 GULF BEACH HWY
PENSACOLA FL
32507-9043
US

IV. Provider business mailing address

12084 GULF BEACH HWY
PENSACOLA FL
32507-9043
US

V. Phone/Fax

Practice location:
  • Phone: 904-864-2351
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01082384A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101241220
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME138422
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: