Healthcare Provider Details

I. General information

NPI: 1609927219
Provider Name (Legal Business Name): JENNIFER M. BENTON PH D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 11/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4520 S HARVARD AVE SUITE 200
TULSA OK
74135-2925
US

IV. Provider business mailing address

4815 S HARVARD AVE SUITE 470
TULSA OK
74135-3055
US

V. Phone/Fax

Practice location:
  • Phone: 918-743-3224
  • Fax:
Mailing address:
  • Phone: 918-392-4866
  • Fax: 918-392-4867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1057
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: