Healthcare Provider Details

I. General information

NPI: 1578375812
Provider Name (Legal Business Name): JAYNA MARIE BENNETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2025
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date: 08/26/2026
Reactivation Date: 09/03/2026

III. Provider practice location address

1015 PENNSYLVANIA AVE
IRWIN PA
15642-3737
US

IV. Provider business mailing address

114 SHADY ACRES RD
JANE LEW WV
26378-1136
US

V. Phone/Fax

Practice location:
  • Phone: 866-287-2036
  • Fax:
Mailing address:
  • Phone: 304-704-5575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: