Healthcare Provider Details

I. General information

NPI: 1821572140
Provider Name (Legal Business Name): JONATHAN ANTONIO BENNETT JR. MA, LPC-A
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2018
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 19TH AVE N # 202B
MYRTLE BEACH SC
29577-3249
US

IV. Provider business mailing address

1909 CAPELLA CT
CONWAY SC
29527-8200
US

V. Phone/Fax

Practice location:
  • Phone: 843-504-6912
  • Fax: 843-326-4848
Mailing address:
  • Phone: 843-450-4055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6918
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: