Healthcare Provider Details

I. General information

NPI: 1548875628
Provider Name (Legal Business Name): JANICE S BENEDICT PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2020
Last Update Date: 02/03/2021
Certification Date: 02/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6975 REDANSA DR
ROCKFORD IL
61108-1201
US

IV. Provider business mailing address

3710 CORBRIDGE LN
ROCKFORD IL
61107-3548
US

V. Phone/Fax

Practice location:
  • Phone: 815-398-7000
  • Fax: 815-395-0671
Mailing address:
  • Phone: 815-399-8040
  • Fax: 815-395-0671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. JANICE STRAND BENEDICT
Title or Position: SOLE MEMBER
Credential: LCSW
Phone: 815-399-8040