=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164429320
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEANNE MARIE BENNETT PSY.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2005
-----------------------------------------------------
Last Update Date | 09/01/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1169 EASTERN PKWY STE 2238
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40217-1444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-376-7552
-----------------------------------------------------
Fax | 502-425-5540
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9012 WILLOW SPRINGS DRIVE
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40242-7763
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-376-7552
-----------------------------------------------------
Fax | 502-425-5540
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | 1034
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 1034
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | 129055
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------