MEDICARE: JERSIAH BENNETT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1316317340
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERSIAH BENNETT

Provider Business Mailing Address
First Line	:	3053 W CRAIG RD
Second Line	:	SUITE E
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-5124
Country	:	US
Telephone Number	:	702-693-7117
Fax Number	:

Provider Business Practice Location Address
First Line	:	3053 W CRAIG RD
Second Line	:	SUITE E
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-5124
Country	:	US
Telephone Number	:	702-639-7117
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/02/2015
Last Update Date	:	10/02/2015

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