Healthcare Provider Details

I. General information

NPI: 1467744003
Provider Name (Legal Business Name): JOFFREE LYNETTE BENNETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2011
Last Update Date: 01/04/2024
Certification Date: 01/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2108 CLUB PACIFIC WAY APT 104
LAS VEGAS NV
89128-0222
US

IV. Provider business mailing address

2108 CLUB PACIFIC WAY APT 104
LAS VEGAS NV
89128-0222
US

V. Phone/Fax

Practice location:
  • Phone: 702-272-7712
  • Fax:
Mailing address:
  • Phone: 702-272-7712
  • Fax: 702-438-4673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11147-M
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: