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General NPI Number Information
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NPI Number | 1891919213
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Entity Type | Individual
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Provider Name | TED BENNETT PH.D.
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Gender | Male
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Dates
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Enumeration Date | 04/13/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1500 E WOODROW WILSON AVE OFFICE A370
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City | JACKSON
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State | MS
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Zip | 39216-5116
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Country | US
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Telephone | 601-362-4471
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Fax |
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Provider Business Mailing Address
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Address Line | 437 MOCKINGBIRD CIR
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City | BRANDON
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State | MS
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Zip | 39047-7337
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Country | US
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Telephone | 601-919-3399
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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 | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number | 46753
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License Number State | MS
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