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General NPI Number Information
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NPI Number | 1508395294
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Entity Type | Individual
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Provider Name | JAMIE MICHAEL BENNETT LCSWA
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Gender | Male
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Dates
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Enumeration Date | 06/07/2017
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Last Update Date | 06/07/2017
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Provider Practice Location Address
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Address Line | EBH 1BCT 5TH ARMORED DIVISION DRIVE
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City | FORT DRUM
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State | NY
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Zip | 13602
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Country | US
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Telephone | 315-772-1451
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Fax |
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Provider Business Mailing Address
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Address Line | 21858 OAK POINTE LN APT C
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City | WATERTOWN
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State | NY
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Zip | 13601-5955
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Country | US
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Telephone | 830-282-9035
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | P009784
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License Number State | NC
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