=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003479171
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN JAMES BENNETT MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2019
-----------------------------------------------------
Last Update Date | 12/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 313 TERRITORIAL ST E
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55388-9284
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-955-1921
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 424 MN-5
-----------------------------------------------------
City | WACONIA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55387
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-442-4461
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 71173
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------