Healthcare Provider Details

I. General information

NPI: 1295757631
Provider Name (Legal Business Name): JASON B. BENNETT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 KENMOOR AVE SE STE 301
GRAND RAPIDS MI
49546-8621
US

IV. Provider business mailing address

770 KENMOOR AVE SE STE 301 STE 301
GRAND RAPIDS MI
49546-8621
US

V. Phone/Fax

Practice location:
  • Phone: 616-290-1876
  • Fax: 616-290-1877
Mailing address:
  • Phone: 616-290-1876
  • Fax: 616-290-1876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number4301076635
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: